Medical Diary In Child Health Care

Information is one of the more important pre-requisites for medical treatment, particularly in a case of a child, who may not always be in a position to recall and share previous events. Even the parents may sometimes miss out on important information, so a document of events, a medical diary, is a really good idea.
Medical Diary in Child Health Care
Source - Wikimedia Commons (https://commons.wikimedia.org/wiki/File%3AChild_receiving_rabies_innoculation.png)

A properly maintained Medical Diary can be a great asset in ensuring proper health care of a child. It can immediately provide all necessary details to a treating paediatrician, even one who has never seen the child earlier. It can facilitate timely immunization, expedite diagnosis in case of a sickness, prevent allergic reactions, and save a life in emergencies.

 

The Medical Diary is supposed to be a record of all relevant information that may have a role in future health care of the child. It is like the complete history of events that any physician would like to know if he

happens to be taking care of that child.

Types of Medical Diary

One can broadly classify the Medical diary for children into two major categories. The first is the Medical diary for normal children. The things that need to be recorded for a normal child pertain to health events, medical interventions and other relevant facts. The other category is the Medical diary for children with a certain medical condition, like Diabetes, Autism, Attentions deficit hyperactivity disorder or Migraine. The things that need to be recorded in such diaries would also include information that is important for monitoring that condition. Often in such cases, information that would be otherwise trivial needs to be observed and noted down.

Records to be Entered in Medical Diary

There is certain information that needs to be recorded for every child, and it may be required any time in future.

(i) Ante-Natal History - The medical history of the child actually starts from the time of conception. All major events during pregnancy should be included here, including threatened abortions, medications taken by the mother, details of mode of delivery and any important events during it. History of any major illness of mother during pregnancy should also be recorded.

(ii) Neonatal History - History of any events in neonatal period, including jaundice - its duration and severity, results of liver function tests, or any other events like cyanosis should be recorded along with treatment prescribed.

(iii) Details of Developmental Milestones - Beginning from weight at birth, and reflexes at the time of birth, all observations made during periodical check up by the nurse or paediatrician should be recorded. These milestones include physical growth, mental growth and social development of the child. The development of milestones should be recorded against the expected age for that milestone to indicate delays if any.

(iv) Immunization History - Immunization history of the child should be recorded in full detail including dates and place of immunization.

(v) History of Disease & Medication - Details of all medication given to the child should be recorded, along with the details of prescribing physician, diagnosis, duration of the treatment given and the details


of all side effects observed during or after the medication.

(vi) History of Allergies - Details of all allergies or hypersensitivity reactions seen in a child, along with their severity, the treatment given and the recovery should be recorded in detail. These include allergies to drugs, milk, dust and other articles.

(vii) Family History - Certain diseases have a hereditary or genetic component. It is better to have a summary of medical history of parents and siblings included in Medical history.

(viii) Travel History - Certain infections are endemic in certain parts of the world, so knowing about the places child has travelled can sometimes provide clues to the possible causes of an ailment.

(ix) Behavioural History - It is usually a good idea to include observations suggesting behavioural deviations in the Medical diary. It can help a great deal sometimes in arriving at the correct diagnosis.

(x) Nutritional History - Detailed chart of everything that a child may eat and drink may not be possible to maintain, but a summary of the feeding habits, if included in Medical diary, can be very helpful for the physician.

(xi) Specific Details as per Need - While all the details above are useful for almost every child, in case of a child with a particular illness or special needs, other details can be very relevant. In a child with migraine, her behavior immediately before the onset of pain, the severity and duration of pain, nutritional history and other details like watching Television can sometimes provide vital clues about potential precipitating factors. For the specific details, one would need to discuss with the concerned physician as to what details need to be recorded and in what detail.

Use of Medical Diary

A properly maintained Medical diary, in whatever form, is a great tool for identifying the health needs of the child. It can help in planning the appropriate nutrition for the child, avoid allergic reactions, save time while planning treatment and prescribing drugs and help in improving the overall efficiency of health care of the child.
 



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