Medical case sheet Documentation for interns mbbs.pptx
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Medical case sheet Documentation for interns mbbs.pptx
- 1. DOCUMENTATION -Case sheet writing -Record keeping -Death notes writing -Communicating death to relatives Dr Harischandra. Y.V. Professor Paediatrics
- 2. What a medical record?
- 3. In legal system-- documentation-- an essential element. Failure to document relevant data is itself considered a significant breach of and deviation from the standard of care. Of course, protection from legal jeopardy is not the only reason for documentation in clinical care. The patient's record provides the only enduring version of the care as it -- evolves over time and -- a reference work of value in emergency care, research, and quality assurance.
- 5. First, record the risk-benefit analysis This risk-benefit analysis should include even obvious or given benefits. Clinicians tend to focus on these possible risks and address them in particular in their record progress notes. - However, the benefits of these medications are often stinted, and the risks of not receiving the medications are often omitted entirely.
- 6. The second --documentation is the use of clinical judgment at critical decision points. There are many possible definitions of clinical judgment, but a useful one for our purposes is an assessment of the clinical situation and a response congruent to that assessment. For example, a clinical judgment and response that reads, Patient still extremely suicidal, discharge today would clearly fail the test of the congruence of the response to the assessment.
- 7. The third sovereign principle of documentation relates to the patient's capacity to participate in his or her own care. Examples of this include the patient's ability to understand the purposes of the -various medications being prescribed, -the patient's awareness of what symptoms to look for regarding exacerbation of the condition, -and the patient's knowledge of what symptoms or states of mind constitute an emergency.
- 9. Documentation Practices (2) Source documentation should be ALCOA: Attributable Legible Contemporaneous Original Accurate
- 10. Documentation Practices (3) Attributable It should be clear who has documented the data Legible Readable and signatures identifiable
- 11. Documentation Practices (4) Contemporaneous The information should be documented in the correct time frame along with the flow of events If a clinical observation cannot be entered when made, chronology should be recorded Acceptable amount of delay should be defined and justified
- 12. Original Original, if not original should be exact copy; the first record made by the appropriate person Accurate Accurate, consistent and real representation of facts Documentation Practices (5)
- 15. What do Doctors feel
- 20. OWNERSHIP OF MEDICAL RECORDS An important issue of dispute between the patient and the treating hospital is about the ownership of the medical records. medical records are the property / responsibility of the hospitals. medical records can be stolen, manipulated, and misused for malafide reasons by any interested parties. An unsigned medical record has no legal validity.
- 22. Retention of Medical records OPD (Out Patient) Records - 5 years IPD (IN patient Records) - 10 years MLC (Medico legal cases) - 30 years Chances of litigation - 25 years
- 23. The initial assessment documentation (details of assessment after admission) is to be done - Within 24 hours Registration & admission process Should be to be documented
- 24. Oral orders should be documented and signed within 24 hours If any drug is given in emergency to save life, it should be documented Abbreviations specific to the hospital cannot be used
- 25. Every sheet in the medical record of patient should have both 1) patient name, gender, age; 2) UHID (Unique Identity number) Any food/drug allergies of the patients should be documented Prescriptions of drugs should be written in capital letters
- 26. The patient & family should be educated about all - a) disease process; b) Cost; c) their rights; d) preventive aspects and complications Informed consents (Consent regarding any treatment or procedure or surgery) shall be taken - By Treating Doctor - And Language Understandable by them
- 27. Blood Transfusion needs consent Consent should be obtained before every procedure and signed by treating doctor.
- 28. In case of patients who have expired when in our care both - death certificate and - death discharge summary Should be given A Post Graduate is responsible for errors in documentation and procedures, not only consultant.
- 30. How do doctors tell family about patient dying? The best practice is to ask the relatives to step away from the bed and guide them to a side-room of the ward or ICU, but this is not always followed. Sometimes, families have to make do with receiving the news of death in a corner of a ward or in a corridor, with no place to sit.
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