Personal Health Plans

Personal Health Records / Care Notebooks

FIN - Family Information Notebook

FIN stands for Family Information Notebook. The notebook is designed to help families coordinate many aspects of their child’s care and health. It can help families and others caring for a child exchange information so the child’s special health care needs can be met appropriately. Families may share copies of any part of their notebook with anyone who works with their child, including family members and friends.

All files are PDF format except where noted.

FIN Section 1: Emergency Plan

This section provides information that you or another caregiver might need if there is a medical emergency with your child. It includes:

Medical Emergency Information: to provide you or another caregiver with information on how to get in touch with the parents / guardian of your child and how to contact services that may be needed in the event of an emergency.
Emergency Room Information: a one-page form containing all of the basic information emergency room caregivers would need to know about your child.
Emergency Information Form for Children with Special Needs: to provide a summary of medical information about your child that can be useful in a medical emergency.
Emergency Names and Numbers: to provide names and numbers of people who are important to your child who may need to be contacted in an emergency.

FIN Section 2: Medical/Health

This section of the notebook contains information on the medical condition of your child. It includes:

Medical Power of Attorney: to give permission for other people you choose to authorize medical treatment for your child.
Medical Care Contact Information: to keep track of the contact information of the doctors, therapists, and other professionals who help care for your child.
Insurance Information: to make copies of your insurance card(s) and policy numbers, including any TennCare information.
Tracking of Medical Bills: to keep track of medical bills received, how much the insurance company paid, and how much the family owes.
Baseline Data: to provide information on the normal physical state of your child.
Doctor's Appointments: to keep track of appointment dates and times and to record any questions, problems, or concerns you want to share with the doctor at the next appointment.
Notes from Doctor's Appointments: to record any diagnosis given by the doctor and to make notes regarding the diagnosis, tests performed, medical advice, etc.
Medications: to provide information on the medications your child is taking or has taken and to record contact information for the pharmacies you use.
Therapy Routines: to describe special routines (suctioning, skin care, therapies, postural drainage, etc.) and times for these routines.
Surgery or Procedures/Hospital Admissions: to record the surgeries and procedures your child has had and when and where the surgeries and procedures took place. The form also provides information on when and why your child has been hospitalized for non-surgical reasons.
Pediatric Immunization Record: to provide information on your child’s immunizations and when each immunization was given. You may also want to attach a copy of your child’s immunization record from his or her physician.
Test Results: to provide information on your child’s eye, hearing, speech/language, and psychiatric tests and the results of those tests, including who gave the test and what the results were.
Dental History: to provide information on your child’s dental problems and treatments and the dates your child has received treatment.
Allergies: to keep track of any drug, herb, food, fabric, animal, latex, and plant allergies your child may have.
Latex Allergies: more detailed information about latex allergies and the types of items that can trigger a latex allergic reaction.

Other information you may want to keep in the Medical / Health Section includes copies of:

Proof of Guardianship -- Keep a copy of the guardianship document to indicate who has legal custody of your child in cases of divorce, etc.
Birth Certificate
Social Security Card
Reports and Notes from physicians, clinics, hospitals, and therapists

NOTE: If your child is hospitalized, you may want to request copies of discharge summaries from the hospital so that information can be communicated quickly to other medical professionals caring for your child.

FIN Section 3: Family/Social

This section contains information about your child’s family, and services that your family receives. It includes:

Family/Social Information: to provide information on family members who live with or care for your child, services your child and family receive at school and in the community, and other information that would be helpful for medical professionals to know about your family.
Important People in My Child's Life: to provide information on family members, friends, and pets that are important to your child and the nicknames your child gives to these people or pets.
Family Health History: to provide information on any conditions or illnesses of close blood relatives of your child.
Information on Genetic Family Tree: if your child’s illness or disability is genetic, this form provides a way to track genetic conditions within the family. This form also allows you to compile the information you need to draw your child’s own genetic family tree.
Sample Genetic Family Tree: an example of how to draw a genetic family tree using particular symbols to indicate males and females, adopted children, and divorces to visually track your child’s family history of genetic conditions.
Genetic Family Tree: a blank page where you can draw your own genetic family tree, using the Information for Genetic Family Tree form and the Sample Genetic Family Tree as resources and guides.

You may want to include other information about your child’s family and important people to your child in this section. For example, describe how sisters, brothers, or other people communicate or play with your child, or how they assist in meeting the needs of your child.

FIN Section 4: Development

This section contains information about your child’s development. It includes:

Milestones: indicates some of the things your child has achieved and the dates of these achievements and gives a place to list your child’s special talents and skills.
Concerns About My Child's Development: provides a list of concerns or questions you may have about your child’s growth or development.
Tracking Growth: may be used with or in place of the physical growth charts to show the development of your child’s height, weight, and head circumference.
Physical Growth Charts: show your child’s growth over time. Growth charts can be downloaded from the Centers for Disease Control and Prevention website.

FIN Section 5: Daily Routine

This section contains information about your child’s routines. It includes:

Mealtime: provides information on your child’s eating times, food allergies, favorite foods, and feeding equipment.
Personal Care: provides information on location of your child’s clothing and instructions for bathing, dressing, toileting of your child, as well as other routines.
Play Time/Study Time: provides information on your child’s favorite activities, toys, music, and books and on TV, computer, and homework rules.
Bedtime: provides information on your child’s physical care and rituals at bedtime.
Transportation: describes what your child needs for traveling, seating instructions, and specific instructions for field trips in programs / schools.

You may want to provide photos of your child to indicate such things as your child’s seating position in the car or for feedings or any other photos which might help others learn about your child’s routines.

If your child is of school age, a lot of the information contained in this section will be helpful to school or program personnel. For example, knowledge of food preferences, best ways of dealing with equipment, and sitting positions may help school personnel better assist your child.

Information on daily medications and therapy routines may be found in the Medical / Health section of the notebook.

IN Section 6: Program/School

This section contains information concerning your child in school settings and other programs and activities your child may be involved in outside the home. It includes:

Schools Attended: provides information on specific educational programs and schools attended by your child.
Health Related School Log: a form to record episodes or events that happen to your child while at school.
Individualized Health Care Plan for Program/School: provides the Program / School with information about your child’s condition, symptoms, and suggested action.
Adaptive Physical Education Recommendation: provides information about restrictions placed on your child’s physical activities.
Request for Assisted Self-Administration of Medications: requests that a student be able to administer his/her prescription or non-prescription medication during school hours.
Physician's Orders and Request for Specialized Health Care Procedure at Program/School: a guide for obtaining written orders from your child’s physician for health care procedures your child needs to receive while attending a program or school.
Other Information Related to My Child's Medical Condition to be Shared with Program/School: provides Program / School with additional information on your child to help others learn how to better assist your child.
Permission to Release Information from Program/School to Physician: indicates what information you would like the program / school to share with your physician.
Permission to Release Information from Physician to Program/School: indicates what information you would like your physician to share with a program or school your child is attending.
Program/School Medical Emergency Plan Checklist: provides information on what should happen if your child has a medical emergency at school.
Permission to Treat: gives consent for your child to be treated if parent / guardian cannot be reached.
Reviewing and Correcting My Child's Student Records: provides a record of steps to be taken to review and correct your child’s school records.
Important Contacts: provides a place to record names, telephone numbers, and addresses of individuals to assist you with information and services for your child.
Special Education Mediation Request: if you have a conflict with school personnel regarding your child’s disability, you may use this form to request a mediation session to try to resolve the issue.

FIN Section 7: Special Equipment

This section may be used to record information about your child’s special equipment.

You may want to provide instructions and pictures or illustrations of how the equipment works so that others will learn how to use it and what to do if it breaks down.

Such equipment may include:

Bili light blanket
Braces
Car seats
Casts
Catheters
Communication devices: typewriters, language board, computers
Feeding tubes (NG, gastrostomy, micky, peg tube)
Feeding pumps
Monitors
Oxygen
Special seating
Splints
Strollers
Toileting
Tracheotomy tubes
Ventilators (e.g. C-Pap Machine)
Wheelchairs

Special Equipment Information Sheet

IN Section 8: Appendices

This section of the notebook contains additional resources you may find helpful either in caring for your child or in using this notebook. It includes:

Calendars: customizable to any month and year to help you keep track of appointments, activities, routines, and important dates.
Glossary of Terms: explains some of the medical terms and acronyms used in the notebook.
Bill of Rights for Parents: clearly lists the responsibilities of hospital personnel and of family members when a child is receiving treatment.
Do Not Resuscitate (Optional Form): communicates a patient’s wish not to be resuscitated in the event of a medical emergency.
Index of Forms: lists alphabetically all the forms and resources found in the notebook.