# 287
In my continuing series on simple things you can do to help mitigate the effects of a pandemic, today we focus on home medical charting.
During a pandemic, we’ve all been told we must expect to care for our loved ones in our home. Dr. Woodson’s guide gives a good deal of information on how to treat avian flu victims, and should, IMHO, be the the starting basis for home flu care.
While Dr. Woodson addressed the need for charting the patient’s condition during an illness, and even provided his SOAP form, I’ve developed my own patient `chart’ which I will use instead. There is nothing wrong with Dr. Woodson’s format, I just find that my form is easier to use, allows for multiple ( 8 ) entries on one page, and is easier to spot trends at a glance. This is strictly a personal preference on my part.
Caveat Lector. Use it if you like it.
I've placed a copy of my `Chart' in .doc (Microsoft Word) format in the Downloads section of the PlanForPandemic flu forum. If you like it, print it out, and make some copies to keep on hand. You will find a wealth of other prepping information, running the gamut from solar energy to food storage at this flu forum. It is well worth a look.
While I developed this chart with Avian Flu in mind, it can be used for other medical conditions as well. People will continue to have heart attacks, strokes, and other medical emergencies during an extended crisis.
WHY KEEP A CHART?
Multiple reasons.
First, by keeping a detailed chart you can tell at a glance whether the patient is improving or not, and can adjust your treatment accordingly.
Second, even when giving OTC (Over the Counter) meds like Tylenol, or Ibuprofen, it is important to track how much you have given, and when. Trying to rely on your memory under stressful and fatiguing circumstance will lead to mistakes. You could accidentally give too much or too little, and compromise the patient’s health.
Third, if more than one person is caring for a sick individual, it allows the handoff of the patient to someone else easier.
And fourth, if additional medical care becomes available (Ie. Doctor or hospital), having an up to date chart on the patient will prove invaluable to the medical staff.
WHAT NEEDS TO BE ON THE CHART?
I’ve divided my chart into two sections. The top section is basic patient information. The bottom section is for charting the patients condition over time.
TOP SECTION
Obviously, the patient’s name, age, gender and approximate weight. Sure, you know your kid’s name, but if your child is transferred to another caregiver, having this identifying information at the top of the chart will be important. Additionally, an address or contact information, along with the DATE should be noted. Some way of noting the page number is also important, as most patients will require several pages of notes.
Next come the Patients Symptoms and Complaints. Symptoms are things like Fever, Nausea, vomiting, muscle aches, or shortness of breath. These are things the patient tells you about how they are feeling.
Following that I have room for Clinical Examination. Skin Color, Texture, heart and lung sounds, states of consciousness, etc. These are the things you observe about the patient.
Allergies, and a list of current Meds are next. Allergies are to meds, or severe food allergies. It would be important to note a penicillin allergy, or an allergy to Corn. If the patient is on meds, they can be listed.
Medical History (Hx) and Initial Diagnosis are next. If the patient is an asthmatic, or has diabetes, or a heart condition, it would be important to note that. While you are not a doctor, you will have to make an assumption of what is wrong with the patient. Just like doctors, you may need to put down more than one thing. In the ER, doctors routinely list 2 or 3 possible diagnoses. FLU is fine. Doesn’t have to be fancy. If you don’t know, write down Unknown.
And Lastly, a Treatment Plan. This may be as simple as Push ORS, Tylenol every 6 hours. Monitor Fluid In/Out.
BOTTOM SECTION
Here I’ve placed 8 charting notes to be filled in. It is customary to check the patient’s vital signs and notate them on a regular basis. Every 2 hours, or 3 hours or 6 hours. How often depends on how ill the patient is. With 8 slots, one page will handle 24 hours worth of charting every 3 hours.
Each slot has the following two line items (note:doesn't format well in this blog):
Time Date Vitals Observations
___:__ __/___ BP ___/___ P ___ R___ T____ ___________________________
Treatment:____________________Fluid In: ______cc Out: ______cc Init ___
These items are pretty much self-explanatory, but in the interest of verbosity, I’ll go into them further.
Time is easiest if entered in Military time, but only if you are comfortable with the format. Otherwise append an A or P after the time to indicate morning or evening.
Date is Month/Day format.
B/P is blood pressure. If you don’t have a blood pressure cuff, consider getting one.
P is pulse rate.
R is respiration rate.
T is temperature.
Observations can be as simple as improving, worsening, fever broke, or dark urine. Just a few descriptive words about how the patient is doing.
Treatment should indicate what you’ve done for the patient since the last notation. Ie. 1 quart of ORS, or Tylenol 1000mg @ (time).
FLUID IN/OUT charts the amount of fluid ingested (or administered IV), and the amount of urine voided since the last chart notation. Keeping track of this is very important in patients. Normally, we note these in cc’s, but you can use ounces, or cups, or whatever. While a patient should take in more fluid than they put out, a wide discrepancy in the two can indicate kidney failure.
And lastly, INIT: a place for the person doing the charting to place their initials.
COMMON MEDICAL ABBREVIATIONS
Abbreviation Meaning Latin Term
ac before meals ante cibum
bid twice a day bis in die
cap capsule capsula
gt drop gutta
hs at bedtime hora somni
od right eye oculus dexter
os left eye oculus sinister
po by mouth per os
pc after meals post cibum
pil pill pilula
prn as needed pro re nata
q2h every 2 hours quaque 2 hora
qd every day quaque die
qh every hour quaque hora
qid 4 times a day quater in die
tab tablet tabella
tid 3 times a day ter in die
While all of this may seem like extra work, I can assure you, it will pay many dividends in the end. Charting helps avoid costly mistakes, and can truly be one of the most important steps you can take when caring for someone who is ill.
Regardless of the format you decide to use, keeping track of your patient, and the medicines you give them, is a critical part of patient care. Deciding how you will do that now, before someone falls ill, will save time and confusion later.
