A doctor’s appointment is short, and the clinician sees the person far less often than the family does. In that time the clinician has to decide what has changed. The family may know, and still arrive with a feeling instead of a record: “She’s been off lately.” A short written log turns that feeling into facts the clinician can compare with last month.
This guide is for whoever is with the person most often, whether a spouse, an adult child, or a paid caregiver who writes notes for the family.
| Instead of | Write |
|---|---|
| Had a bad night | Up at 1, 3, and 4:30 a.m. to use the bathroom; said it burned. |
| Not eating well | Ate half a sandwich at lunch, nothing at dinner, Tuesday and Wednesday. |
| More confused | Did not recognize her kitchen Thursday at 6 p.m.; normal again by breakfast. |
Five things to record for any change
When it started. The date, and whether it came on over hours, days, or weeks.
When it happens. Morning, evening, after meals, after a new medication.
How often and how long. Once, every day, or several times a day, and for how long each time.
What was going on around it. A new medication, a missed dose, a fall, a cold, a change in routine, poor sleep.
What helped or did not. Rest, food, fluids, a quiet room, a phone call.
The speed of a change matters. A change in thinking that appears over hours or days can signal an illness such as an infection. Call the clinician the same day.
Keep it short enough to keep going
Keep entries short so the log keeps going. One line per entry, with the date and time, is enough. Keep the log in one place, such as a notebook in the kitchen or one shared note on a phone, so a sibling or a caregiver can add to it.
OPA’s free Observation Log gives a printable page with examples. It belongs inside the Family Care Notebook, which keeps medications, providers, and questions together so another person can pick it up.
At the appointment
Bring the log and a current medication list. Before the visit, read the last few weeks of entries and write the one or two changes you most want the clinician to hear. Say those first. Leave the log with the clinician’s staff if they will take a copy.
After the appointment, write down what the clinician decided, who owns the next step, and when to follow up.
A first step today
Start the log with one line for today, with the date and time, describing one thing you saw. Add a line each day this week.
This is general information, not medical advice. Bring new or worsening symptoms to the person’s clinician, and call 911 for an immediate emergency.
For a reliable next step, use National Institute on Aging information on memory changes for the official details, then use how care starts when your family needs to organize support at home.
For a related decision, MedlinePlus guidance on health records can help frame the question, and this site’s Next-of-Kin Box guide offers a practical next step.
Families can also compare the next handoff with OPA’s Care Coordination Grid.
