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Documentation For Your Loved One

If you have a loved one who is elderly, chronically ill, or disabled, having a notebook dedicated to the documentation of their healthcare is a very good idea, whether they live in a facility or at home. When your loved one is hospitalized or in a facility (e.g.: nursing home, assisted living, etc), it is prudent to carefully document the details of their stay, as well as any conversations with facility staff. And if you are ever in the unfortunate position of lodging a complaint or taking legal action, documentation is key to building a successful case.

A Dedicated Notebook

Mi Casa recommends that you have a dedicated notebook in which you record all conversations with facility staff, medical providers, insurance companies, and others. A three-ring binder with several sections is the best choice; you may consider having the following sections in your binder:

  1. Notes from medical visits

  2. Documentation of conversations with facility staff

  3. Lab results, x-rays, and diagnostic tests

  4. Printed email exchanges with all parties

  5. Insurance: letters, documentation, etc

  6. Medications, allergies, and prescriptions

  7. Contact information of all providers

  8. Other documents: DNR, POA, Five Wishes or Health Care Proxy, etc

This notebook can be the central location where all pertinent information is kept; if various family members are involved in your loved one’s care, the notebook can be shared so that each member is aware of the full picture, with access to all necessary information. Make sure that the notebook contains copies of insurance cards, health care proxies, POA and DNR forms, as well as social security number and other important information.

Some families may choose to digitize information and share it electronically; please be aware that unless you have access to an encrypted cloud, the privacy of your loved one’s information may not be fully protected.

21st-Century Complexity

21st-century healthcare is complicated; from insurance and guardianship to hospitalizations and the management of medications. In order to navigate the complex nature of your loved one’s care, use careful documentation to keep track of the many aspects that require attention.

In terms of documentation, you may communicate with a number of providers, including home health agencies, specialists, and insurance companies. Record first and last names of all parties, as well as dates and times of all conversations (phone and in-person). If you are involved in a face-to-face conflict with a medical professional or facility staff, record names and contact information of all witnesses.

While focusing on our loved ones’ care, we may sometimes feel overwhelmed by the many details we’re juggling. Conscientious record-keeping provides peace of mind that everything is documented in the interest of timely follow-up and accurate documentation.


Keith Carlson, RN, BSN, NC-BC is the Chief Nursing Officer of Mi Casa Home Health Care. Keith has been a nurse since 1996, and has focused the majority of his nursing career on home health, hospice, case management, and public health. He is a well-known nurse career coach, nurse blogger, freelance writer, speaker, and podcaster. Keith lives in Santa Fe, New Mexico.

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