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Personal Health Records / Care Notebooks

Downloads - Templates & Forms

Center for Medical Home Improvement
CMHI promotes the medical home as a family-centered “way of doing things” for CSHCN; this includes how practices partner with, respond to, and care for children, especially those with or at risk for developing special health care needs. CHMI makes the following sample plans available:

Other downloads from Center for Medical Home Improvement

The National Center for Medical Home Initiatives

Integrated Services Care Plan: pdf PDF | MS Word Version MS Word
A comprehensive assessment that includes: demographics, current problems with status, routine health maintenance, specialty care, medical support services, hospital care, education, rehab services, pharmacy needs, medical equipment/home care, community services, and a parent/caregiver signature page. Developed by the PA Medical Home Program - EPIC IC.

Emergency Preparedness for Children with Special Health Care Needs
To facilitate prompt and appropriate emergency care for children with special health care needs, the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) have developed an Emergency Information Form and other materials which can be used as a tool to transfer critical information about these children. It is hoped that the form will gain acceptance and be utilized by primary caregivers and specialists so that emergency physicians may have access to vital information when emergencies occur.

 

MyPHR Forms - Adult Forms
This fifteen-page form contains space for recording: Allergies, Identification, Medical history, Major illness/operations, Medications, Infectious diseases, Immunizations, Health maintenance, Devices and prostheses, Eye information, Healthcare documents, and Family medical history.

Child Form
This five-page form contains space for recording: Allergies, Identification, Birth date, Growth and development, Immunizations, Medications, and Infectious diseases.

Health Forms and Records by Dr. Marie Savard

Dr. Savard's Forms (Link takes you to another page on this CD)
Dr. Savard is Author of How to Save Your Own Life: The Savard System for Managing--and Controlling--Your Health Care and The Savard Health Record.

My Family Health Portrait
U.S. Surgeon General's Family History Initiative

Care Notebook - Washington
The Care Notebook and Care Organizer are tools for families who have children with special health care needs developed in Washington State Children's Hospital and Regional Center. Families use Care Notebooks to keep track of important information about their child's health and care. This makes it easier to find and share key information with their child's care team. These tools are available in English, Spanish, Russian, and Vietnamese.

Family Information Notebook (FIN)
The Family Information Notebook (FIN) was developed at Children's Hospital at Vanderbilt. 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.

Vital Records Guide PDF pdf |
The Vital Records Guide gives parents an easy way to record the information they need to deal with physicians,
hospital records personnel, therapists, insurance firms, federal, state and local agencies and organizations, direct support
professionals and all other professional and personal support personnel needed provide the appropriate care for a
child with a disability or chronic illness. Pages from the printed guide can be easily copied. From the Arkansas Governor’s Developmental Disabilities Council.

My Child's Life Care Notebook and Organizer
The "My Child's Life Care Notebook and Organizer" is offered free to parents of children with disabilities. This organizer was developed to help families record and track the day-to-day needs of children with disabilities. From the Jean Baton Swindells Resource Center for Children and Families at Providence Medford Medical Center in Oregon.

The Maine Health Care Notebook PDF pdf | MS Word MS Word |
The Maine Care Notebook is a health care notebook will help you keep information organized in a central location. Developing a health care notebook for your child will also make it easier for you to share information with others who are part of your child's care team.

Child’s Personal and Portable Health Record
From the Alameda County Medical Home Project, adapted from the Southwest Institute for Families of Children with Special Needs
Child Health Status Assessment

Utah Care Notebook PDF pdf |
This Care Notebook is an organizing tool for families who have children with special health care needs. Utah created the book to help families keep track of important health care information, list providers and community organizations contact information, prepare for appointments and file and share health history. Utah Family Voices shared this guide so that other resource centers may use this as a template when developing similar tools.

Build Your Own Care Notebook
http://www.medicalhomeinfo.org/CareNoteBook/ Website
Extensive list of sample plans to download from the National Center of Medical Home Initiatives from the American Academy of Pediatrics. Organized by topic area.

Other Templates: