cell phone notes

Start today keeping standardized notes to improve communication with your loved one’s medical professionals.  Choose a way to do it that can be copied to the doctor’s records at your next appointment.  Can you print from the Notes section of your cell phone, or do you prefer keeping a paper record?  When you have your own copy of My Pain AlertScale Communication Tool, you can continue record keeping and show the learning process of your loved one.

Write down your loved one’s name and date of birth and the year you start the record keeping.  Each time you give them pain medicine, start the line with the month, the day, and the letters MU for medicine use.  Next, write how the individual let you know he was in pain:  facial expression, sounds, gestures, speaking, crying, pointing, acting out, coming to you, screaming, …  Next write the medication given and the time.  Wait the time it takes the medicine to work and write whether it worked, and any impressions you have.

That’s it – you now have a record of behavior at the time of pain for someone who has a hard time expressing their needs for pain management.  As caregiver and record keeper, you can abbreviate words that are repeated from one record to the next.  Be sure that the word you want to abbreviate is written out the first time with the abbreviation following it in parentheses.  See how it is done in the example below:

Example:

Joey  born 8/7/14

Date        Action          Individual’s Response                         Plan                    Result

10/18 MU (medicine use) Facial expression (fexp.), fussy (fus.) 3:40 p.m. Acetaminophen(A)-1 children’s chewable, 3:55 p.m. less fussy.

10/19 MU  fexp, fus, 7:20 a.m. A-1, 7:40 a.m. calmer, looks like an ear infection, will call doctor.

For an easy print version of these Care Giver Notes, please click here.