Two years after treatment, someone needs to know which medication was tried and at what dose, or
whether a liver test was ever done, or exactly when the person was admitted. Nobody remembers. The
centre may or may not still hold the file. The family has a plastic bag with three receipts in it.
Keeping records is unglamorous and it repeatedly turns out to matter — for a new doctor, a
readmission, an employer, a legal process, or an insurance claim.
What to keep
From the treatment centre
The discharge summary. The single most important document. It should state the diagnosis, what
treatment was given, medications and doses, physical health findings, and the follow-up plan.
If you were not given one, ask for it. A centre that cannot produce a discharge summary is a
centre whose record-keeping should have been a question before admission.
Also keep:
- The admission record and dates
- Any assessment reports
- Test results — liver function, hepatitis B and C, HIV, tuberculosis screening, blood counts
- The treatment plan and any progress reports shared with the family
- Fee receipts and the fee schedule
- The centre’s contact details and the name of the counsellor who worked with the person
Medication
- Every prescription, dated
- A running list: medication name, dose, start date, stop date, and why it was stopped
- Any recorded adverse reaction — this is safety information that must travel with the person
- Pharmacy receipts
Why the running list matters: a new prescriber needs to know what has been tried. “He was on some
tablets, white ones” is not useful. A medication that caused a bad reaction, if forgotten, will be
prescribed again.
Ongoing care
- Appointment record — date, who was seen, what was decided
- Counsellor’s name, qualification and contact details
- Referral letters
- Any hospital admission, including emergency attendance
- Test results from any follow-up investigation
Identity and legal
- Citizenship certificate copy
- Any court documents, if there has been legal involvement
- Employment records relevant to leave taken
- Insurance policy documents and claim correspondence, if applicable
The family’s own record
Not medical, and genuinely useful:
- The written family agreement, with the dated revisions
- Brief notes from the weekly check-ins
- A dated note of any significant event — a lapse, a hospital visit, a change in medication, a change
in circumstances
This record answers questions nobody else can: how long the good period lasted, what preceded the
last setback, whether things are better than a year ago. Memory is unreliable and biased toward the
recent, particularly under stress.
How to keep it
One physical folder, one digital copy.
Physical: a single file with labelled dividers — treatment, medication, appointments, tests,
financial. Kept in one place that everyone in the household knows.
Digital: photograph every document as you receive it. Store in one folder, named by date and
type: 2026-05-12-discharge-summary.jpg. Back it up to a second place — an email to yourself, a
cloud account, a relative’s phone.
Photograph immediately. Documents are lost, damaged by water, or taken to an appointment and not
returned. The photograph takes ten seconds.
Keep a one-page summary at the front of the folder:
Name: __________ DOB: __________ Blood group: ______
Diagnosis: _______________________________________
Treatment: [centre], [dates]
Current medication: ______________________________
Allergies / adverse reactions: ___________________
Counsellor: [name, number]
Prescriber: [name, number]
Treatment centre: [name, number]
Emergency contact: [name, number]
Last updated: __________
In an emergency, this page communicates in thirty seconds what the folder takes twenty minutes to
convey.
Privacy
These records contain sensitive medical information about an adult.
The person’s information belongs to them. Where they are able to manage their own records, they
should — with a copy held by the family for emergencies, by agreement.
Agree who has access. One or two people, named. Not every household member.
Store securely. Not on a shelf in a shared room, not in a phone gallery that visitors scroll
through.
Do not share without permission — not with relatives, not with an employer, not with a
prospective spouse’s family. Medical information disclosed without consent damages trust
irreparably and can cause serious harm to the person’s employment and social position.
Exception: in a medical emergency, provide what treating clinicians need. That is what the
summary page is for.
When these records matter
A new doctor or a new centre. Complete history, immediately, instead of starting from nothing.
Readmission. What was tried, what worked, what did not.
An emergency. Current medication and known reactions can matter urgently.
A legal process. Where there has been a court matter, evidence of treatment and continued
engagement can be relevant.
Employment. Where an employer requires medical documentation for leave taken.
Insurance. Claims require documentation, and retrospective collection is difficult.
Disputes about children’s care. Documentation of who has been caring for children, and of a
parent’s treatment history, can matter.
The family’s own decision-making. Looking back over two years of notes is the clearest way to
answer “is this getting better?”
How long to keep it
Indefinitely for the core documents — discharge summaries, test results, the medication list.
These are permanent medical history.
At least five years for appointment records, receipts and correspondence.
The family’s own notes: as long as they are useful. Many families keep them permanently; some
destroy them once things are stable, which is a reasonable choice if the person prefers it.
What not to keep
Photographs or videos taken during intoxication. Sometimes families record these as evidence or to
show the person later. They are humiliating, they rarely produce the intended effect, and they can
cause serious harm if they circulate. Delete them.
Detailed accounts of incidents, unless there is a specific legal reason. A written record of every
humiliation is not useful and it makes the past permanently present.
Anything you have collected covertly — read messages, recorded conversations. If it was obtained
without the person’s knowledge, keeping it compounds the breach.
A ten-minute setup
If you have nothing organised:
- Find every document you have. One pile.
- Photograph each one.
- Sort into five categories: treatment, medication, appointments, tests, financial.
- Write the one-page summary.
- Put the physical file somewhere agreed and tell the household where.
- Back up the photographs to a second location.
- Add each new document on the day you receive it.
Frequently asked questions
What if the centre will not give a discharge summary?
Request it in writing. Patients and their families are ordinarily entitled to a record of treatment.
If it is refused, note that fact — and treat it as information about the centre.
Should the person keep their own records?
Yes, where they are able. Autonomy over your own medical history is part of adult recovery. Keep a
family copy for emergencies, by agreement.
Is it legal to keep records about an adult family member?
Keeping documents you were given is ordinarily fine. Obtaining medical information without consent,
or disclosing it to others, is a different matter. Ask before sharing anything with anyone.
Do I need the original documents?
Keep originals where you have them. Photographs are for backup and for quick access, and are usually
accepted for reference, though some formal processes require originals.
What about very old records from previous treatment?
Keep them. Previous treatment episodes, what was tried and what happened are directly relevant to
current care.
Related: Choosing an Aftercare Counsellor ·
Aftercare in Districts With No Services
