One lesson I recently learned the hard way can help you avoid problems when you or a loved one is hospitalized:  keep a notebook in the patient’s hospital room. 

I thought I would be even smarter – I jotted down key points on a notepad, then turned my scribbles into electronic notes.  But several important issues fell through the cracks, because this information wasn’t in the hospital room where it could be used by other people watching out for my relative, such as aides I brought in from outside the hospital and family members without smartphones.  A notebook is more useful.

In the front of the notebook, record contact information for all key people/organizations involved:  surgeon, hospitalist, primary care doctor, family members who may make decisions on behalf of the patient when the patient can’t, the Patient Relations department, the hospital itself, along with the extensions for any people or departments you have reason to call, etc.  Leave extra space, as more people or organizations that you need to know how to reach will surface, even during a short hospital stay.

Then have pages where you can record doctors’ orders:  for drugs, treatments such as physical therapy, tests, and so forth. Include all the details.  For example, for a drug, include the dose (500 mg, for example), the frequency (e.g., every four hours), and whether it is ordered p.r.n., which means “as needed,” or whether it will routinely be given according to a schedule.  Leave extra pages, as doctors’ orders can change.    

Next, set aside some pages to track drugs actually given (by mouth, injection, IV, and so forth) including the date, time, name of the drug, and the amount.

After that, log events as they occur.  For example, when doctors, nurses, or other caregivers enter, note the date, time, name and/or role of the individual (e.g., “nurse—Jeanne”), and what they said or did.  If you want, omit things like delivering meals or emptying the wastebaskets.  Include anything striking about the patient’s condition, e.g., “calm and alert after breakfast” or “could not be roused until noon.“ 

Hospital stays are confusing experiences, for both patients and family members.  Your notes can help answer questions such as, “Did the surgeon say she was supposed to wear the brace all the time?” “Did they bathe her and change the sheets this morning, or was that yesterday?”  “Has it been more than two hours since they came in to reposition her?”

Finally, have a section in which you can write down questions (leaving space for answers).  This way, when a doctor or nurse comes in, you can see everything you wanted to ask, and record who gave you an answer, when, and what they said.