MEDICAL DOCUMENTATION in THE PRESENT CONTEXT.pptx

MEDICAL DOCUMENTATION in THE PRESENT CONTEXT

1. MEDICAL DOCUMENTATION in THE PRESENT CONTEXT Ashwani K Sood Medical Superintendent, MMI MSR Mullana

2. REGISTERS PNDT REGISTERAS PER PNDT RULE SECTION 9(1) MTP REGISTER ; ADMISSION REGISTER FORM III STERILISATION AND IUCD REGISTER BIRTH AND DEATH REGISTER MEDICAL CERTIFICATE BOOK DRUG REGISTER VACCINATION REGISTER MLC REGISTER INDOOR CASE RECORD

3. Discharge Card DAMA Certificates Death Certificates Files Registers Under Different Acts: MTP/PCPNDT/ART/MLC Staff Attendance Salary Register Consultant Payments Register TDS Register REGISTERS

4. INDOOR CASE PAPER RECORD INCLUDE Patient Registration Form Admission Consent Chief Complaints Relevant History, Clinical Examination Reaching Provisional Diagnosis Investigations( All Investigation Reports And Confirmation Of Diagnosis Counselling (Medical/ Financial/Psychological ) And proposed Plan Of Action Consents: admission/financial/ surgical/ consent to photograph/ publishing clinical information for research and training purpose without revelling identity of patient

5. INDOOR CASE PAPER RECORD INCLUDE Preoperative Check Ups Physicians And Anaesthetist Pre op Anaesthetist Notes Operative Notes In Detail With Detail Notes Of Reasoning Postoperative Examination And Orders Nursing Monitoring Chart Daily progress notes Checklist Discharge Card Numbering Of Each Page Of Indoor Record Send Records To MRD

6. Opd consultation sheet ( opd paper) Its an important document All clinical details including present complaints, relevant past history family history clinical findings and provisional diagnosis should be mentioned Treatment with detail instructions related to dosages should ne written precisely Investigations advised if any should be recorded in writing

7. Consents: What all should it include? SAMEERA KOHLI VS DR PRABHA MANCHANDA JUDGEMENT OF SUPREME COURT: LANDMARK JUDGEMANT IN 2008 CRIETRIAS LAID DOWN FOE REAL CONSENT: IT SHOULD COVER Nature And Purpose Of The Procedure Likelihood Of Success And Failure Of Procedure Alternative Treatment Options Available (If Any) Outcome Associated With No Treatment At All In Present Situation. Instructions Concerning The Procedure To Be Adopted In Case Of Failure Of Procedure Or In Case Of Complications

8. CONSENTS IN OBSTETRICS AND GYNAECOLOGY

9. Always Keep Copy Of Discharge Cards It is face of your hospital in the society.

10. Discharge card SHOULD INCLUDE Course of patient hospitalisation Treatment received Date and time of admission and discharge/transfer/death/ DAMA. Clinical findings Past history Investigations in detail

11. Discharge card SHOULD INCLUDE Medical/surgical treatment in details Progress/ complications if any Provisional and final diagnosis Medicines to be take after discharge Dietary instructions Follow-up instructions/ precautions/visits

12. Remember Things That Are Not Written On Paper Are Not Done In Reality

13. There are cases on record where doctors are held liable for damages following patent receiving wrong medicines from pharmacist due to bad handwriting

14. Medical certificates duties of doctor in relation to certificates CERTIFICATES SHOULD BE ISSUED RESPONSIBLY. PURPOSE OF ISSUING CERTIFICATE SHOULD BE MENTIONED IN CERTIFICATES CERTIFICATES SHOULD BE PREPARED IN DUPLICATE . ONE COPY REMAINS WITH TREATING DOCTOR IDENTITY OF PATIENT SHOULD BE CONFIRMED BEFORE ISSUING CERTIFICATES . IDENTFICATION MARKS SHOULD BE MENTIONED ON CERTIFICATES PREFREABLY. DEATH CERTIFICATES SHOULD BE ISSUED AS PER GUIDELINES FOR DEATH CERTIFICATES