The Importance of Record Keeping

By keeping records of our children’s care, we can help them receive better care along the way.

Keeping mental health records for your child can greatly improve the outcome. So, you will want to keep very meticulous records. If your child starts and stops different treatments, this will help you and his care team to know what did and did not work for him in the past. It is also helpful when having to meet with somebody new and get them up to speed on what has been tried so far.There are multiple ways to organize this information. Everything can be done on the computer by scanning in important documents and organizing them there. Or using the binder, you can use tables by either creating them or using the templates provided.

Using a three-ringed binder will be the easiest way to keep all of this information together. You can place loose leaf lined paper for notes. You will be able to place all records and documentation inside by using a three-pronged punch. By using dividers you can organize everything by subjects such as discharge papers, diagnoses, medications, list of doctors, insurance, moods including increase or decrease in symptoms, care plan, safety plan, crisis plan. You will also want to have an area for keeping notes on conversations, who did you speak with, what was it about, when did you talk with them, where was the conversation held, and how it was resolved. This will all come in handy if you ever have to show that you are not receiving proper care or that you are doing all you can to get your child proper care.

Place all insurance documents in the front of the binder. This way you always have it where it is easily accessible. Here you will want to have the conversation templates (free under resources at for noting any conversations concerning mental health coverage. If you have this in front of you at the time of the conversation, you will be sure to gather all needed information so that it is properly documented. Next, list all doctors and clinicians associated with your child’s medical and mental health care with their recommendations and what diagnosis they gave your child.The medication template will contain columns for medication name/dosage/time, any side effects, weight gain or loss, increase or decrease in symptoms start and stop date, the reason for discontinuation or change in dosage, and comments by the prescribing doctor. In the back of the binder, you will keep all discharge papers along with the care plan from any hospitals (most children never have to be hospitalized).

The care plan is what you and the hospital have agreed to for post-discharge care. This will involve following up with the child’s outpatient care team. It will list medications, dosage, time to take it. There may be a list of your child’s identified triggers and coping skills. Triggers are the things that negatively affect your child’s ability to cope. Coping skills are just as it sounds skills learned to better manage reactions when triggered.You can help your child discover new coping skills just by doing a search for coping skills for kids or teens. Make a copy of his preferred coping skills and put it somewhere that is easily seen by you and your child. Never use coping skills as a punishment. It should be used in a way that makes your child want to do it. Most kids are pretty resistant to doing them. But if you model the use of coping skills when you are stressed, this can greatly increase the likelihood of them using them.

There should also be a safety plan with discharge. This is the plan you have all come up with together to keep your child safe at home. It will likely include locking away all knives including kitchen knives, locking away medications, and anything else that has been identified as potentially dangerous.

A crisis plan is a detailed action plan of what to do in the event of a mental health crisis. Sometimes hospitals will create one with you. I know a lot of what you just read has been about hospitalization. Not all children diagnosed with a mental illness have to be hospitalized. But since some do, I have included the information.

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