DOCUMENTATION FOR MEDICAL STUDENTSBalasubramanian Thiagarajan

WHY THIS PROGRAMME? • You are our tomorrow• You are our front end• I assume you are all trainable

DOCUMENTATION IN MEDICINE WHY?

• To ensure better care• To ensure that the patient has a recorded version of the ailment and

treatment given• For publishing papers• For future health care plans• To settle insurance claims

An open mind and open wound heals the best

TYPES OF DOCUMENTATION• Classic manual method• Electronic method• A combination of both

Lives depend on you filling up the pt record accurately and legibly

WHAT AILS OUR SYSTEM• Only 1% of our current documentation is accurate• Only 0.5% of this documentation is submitted to authorities• Our health care planning currently is based on knee jerk reaction driven

by events and circumstances.• We account for only 0.05% of the currently published scientific literature• We don’t use online documentation, hence data cannot be stored with

safety and reliability.

IMPACT OF GOOD DOCUMENTATION

• Patient care and clinical outcomes• Physician to physician communication• To the betterment of health care system

IMPACT OF DISCHARGE SUMMARY

• Must be short / concise• Helps in accurate follow up of

family physicians• Incidence of post discharge

complications are high inpatients with inaccurate discharge summaries

IDEAL DISCHARGE SUMMARY• Admitting diagnosis• Examination findings and lab results• Procedures performed while in hospital• Discharge diagnosis• Active medical problems on discharge• Arrangements for follow up• Medications prescribed on discharge• Follow up plans• A case summary

WHAT AILS CURRENT DOCUMENTATION EFFORTS

• Used as a tool to recall events rather than as means to justify treatment decisions

• It is still manual • Virtually no archiving facilities• Our hospitals have no byelaws governing documentation efforts• Regulators virtually non existent• No privacy legislation

IDEAL DOCUMENTATION SCENARIO

• Admission slip to be issued immediately and entered into patient database

• History taking, clinical examination, case sheet writing should be completed within the first 2 hours of admission. The same should be entered into the patient database within 48 hours

• All patients who are in the ward for more than a week should be evaluated by the medical board constituted by the hospital management

• Proper discharge summary should be issued to the patient immediately on discharge

CASE SHEET• Should be legibly written• No unapproved abbreviations should be used• Every entry should be dated. Timed and signed• Every case sheet should have the name of the pt, age, sex, IP number

and date of admission clearly written on the front page.• Name and signature of the admitting doctor should be found on the front

page of the case sheet• If it is a medico legal case sheet it should be clearly written on the front

page• Final diagnosis and ICD 10 coding of the disease should be clearly marked

on the case sheet of the patient on discharge

ROLE OF INTERNS• Seeing• Observing• Learning• Documenting

ROLE OF MRD• To maintain hospital statistics• To maintain patient case sheets• To submit statistical report to administrators• To facilitate conduct of monthly Institutional audit meetings

CM INSURANCE SCHEME• LO• DMO• Final authorization

Thank you