Essential Medical Documentation

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Essential Medical Documentation required Legally & medically in a Medical Practice

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Essential Medical Documentation

  1. 1.  Medical Council Criminal Court Civil Court Consumer Redressal Forum Janata Durbar! (most dreaded)
  2. 2. III C RegisterCase papersPrescriptionsLegal DocumentsCertificatesReferral LettersAccounts
  3. 3.  Date Sr.No. Patient’s Name in Full Diagnosis Treatment (Service given) Fees Balance
  4. 4.  Sr. No. Full Name Full Address Contact Number Age Sex Clinical Notes Treatment Other Details
  5. 5.  A4 or may be smaller Your name Degree Registration No. Clinic Address Contact Numbers Email ( Optional) Clinic Times & Weekly Off Day (Optional)
  6. 6.  Preferably in Neat ,Good, Legible hand writing Drugs in CAPITAL LETTERS Strength of medicine must be written Correct dosages With clear instructions of frequency of intake On Letter pad or Plain Paper with seal. Seal must have Name, Degree, Reg.No., Address Not on Medical Store or paper with Pharma advt Date, Address and Registration No & proper signature is must Preferably give follow up date
  7. 7.  THISIS THE SIMPLEST FORM OF DOCUMENTARY EVIDENCE & MAY PERTAIN TO SUCH FACTS AS – BIRTH SICKNESS COMPENSATION VACCINATION DEATH
  8. 8. 1. COURT OF LAW2. I.P.C.- SEC.-197 - SEC.- 4633. I.M.C.4. CIVIL SUIT FOR COMPENSATION
  9. 9. 1. LETTER HEAD2. RELEVANT INFORMATION3. TRUE STATEMENTS4. DATE & TIME OF ISSUING CERTIFICATES5. IDENTIFICATION MARKS OF PATIENT6. SIGNATURE & /OR LT. HAND THUMB IMPRESSION7. CARBON COPY8. CAN CHARGE EXCEPT DEATH CERT
  10. 10. 1. BIRTH CERTIFICATE2. SICKNESS CERTIFICATE3. FITNESS CERTIFICATE4. VACCINATION CERTIFICATE5. CERTIFICATE ON WILL6. MENTAL FITNESS CERTIFICATE7. DOMICILLIARY TREATMENT CERT.8. LIFE CERTIFICATE
  11. 11. 9. CERTIFYING LT. HAND THUMB IMPRESSION10. CERT. FOR OPINION IN CASE THE PATIENT IS REFERRED FOR MEDICAL OPINION11. CERTIFICATE OF INJURY12. CERT. FOR L.I.C. POLICY13. CERTIFICATE FOR WITHDRAWING MONEY FROM PROVIDENT FUND14. DEATH CERIFICATE
  12. 12. 1. RESPONSIBILITY OF DOCTORS/ HOSPITAL2. INFORMATION IN WRITING FROM FATHER & MOTHER OF THE CHILD WITH THEIR SIGNATURES.3. OFFENCE IF NOT REGISTERED.
  13. 13. 1. NO BACKDATED CERTIFICATE2. PREPARE A CASE PAPER3. CERTIFY ONLY WHEN UNDER YOUR CARE4. SHOULD INCLUDE- a. Nature of Illness b. Approximate Period for Treatment5. IDENTIFICATION MARKS6. SIGNATURE OR LT. HAND THUMB IMPRESSION OF THE PATIENT
  14. 14. 7. DOCTOR’S SIGNATURE,DATE & TIME8. Carbon Copy9. TREATMENT PERIOD PROPORTIONATE TO THE ILLNESS
  15. 15. I, Dr. ------ after careful personal examination, do hereby certify that Mr./Mrs./Ms……………….( whose signature is given below is suffering from ----- ------ and I consider that a period of absence from duty of about -----days/weeks is necessary for the restoration of his/her health with effect from -------.Identification marks-(i) ------- (ii)-------Signature of Mr./Mrs./Ms. Signature of Doctor Date- Time-
  16. 16.  Recovery after Illness Consider the purpose for which fitness is required Pay Attention to COLOUR VISION Identification Marks of the Patient Signature/ Lt. Hand Thumb Impression of the Patient Signature of Doctor with Date & Time
  17. 17.  Record Your Observation of Medical Examination Keep a Carbon Copy
  18. 18. This is to Certify that, I have examined Mr./Mrs./Ms. -----------today, (Whose signature is given below) & find that he/she has recovered from his/ her illness and in my opinion, is physically fit to resume his/ her duties from today/tomorrow i.e.-----Identification marks-(i) ------- (ii)-------Signature of Mr./Mrs./Ms. Signature of Doctor Date- Time-
  19. 19.  CERTIFY ONLY WHEN YOU HAVE VACCINATED NO FALSE CERTIFICATE MENTION :-1. Name of Vaccine Administered2. Name of the Manufacturing Pharma Co.3. Batch No.4. Mfg. Date5. Exp. Date6. Date & time of Administration
  20. 20.  Case Paper Identification Marks of the Person Vaccinated Signature/ Lt. Hand Thumb Impression of the Person Vaccinated Doctor’s Signature with Date & Time Carbon Copy
  21. 21.  Examination of the Person Case Paper Records in Diary:-1. Name of the Person2. Age3. Address4. Place Where the Cert. is Issued5. Date & Time6. Case Paper No.7. Findings in Diary
  22. 22.  Preserve the Diary FOREVER Signature of the Person Signature of the Doctor, Date, Time & Seal
  23. 23. This is to Certify that, I have examined Mr./Mrs. ------ --- today. In my opinion, at the time of the examination he/ she is mentally competent to depose his/her assets and for executing this document. Identification marks-(i) ------- (ii)-------Signature of Mr./Mrs./Ms. Signature of Doctor/Lt. Hand Thumb Impression Date- Time- Seal
  24. 24. This is to Certify that, I have examined Mr./Mrs. --------- today. In my opinion, at the time of the examination he/ she is mentally in a sound condition of health.Identification marks-(i) ------- (ii)-------Signature of Mr./Mrs./Ms. Signature of Doctor/Lt. Hand Thumb Impression Date- Time- Seal
  25. 25.  EXAMINATION CHECKING & VARIFYING OF DOCUMENTS XEROX COPIES OF THE DOCUMENTS SATISFY ABOUT i. DIAGNOSIS ii. TREATMENT
  26. 26. This to certify that I have examined Mr./Mrs. -------- today. After going through the records of the investigations, other records & the clinical examination, I am of the opinion Mr./Mrs.------- is suffering from ------- . He/ She needs domiciliary Treatment for this condition.At present, he/she is taking following medicines-------------.Drugs & doses may change as per the condition that time.Identification marks-(i) ------- (ii)-------Signature of Mr./Mrs./Ms. Signature of Doctor/Lt. Hand Thumb Impression Date- Time-
  27. 27.  Why is it required? Examination of the person Carbon Copy
  28. 28. This to certify that, I have examined Mr. Mrs.-------- today. He/She is alive today on ------- at ----------a.m./p. m.Identification marks-(i) ------- (ii)-------Signature of Mr./Mrs./Ms. Signature of Doctor/Lt. Hand Thumb Impression Date- Time- SEAL
  29. 29.  Why is it Required? To Known person only Taken on the Bank’s withdrawal Slip- filled in completely Thumb Impression in Your Presence Record in a Diary FORMAT: Lt. Hand Thumb Impression of Mr./Mrs. ----------is taken in My Presence. Signature of DoctorDate- Time- Seal
  30. 30. GIVEN IN CASE THE PATIENT IS REFERREDFOR MEDICAL OPINION. Why is it required? Who is expected to do this Medical Examination? Examine the Patient Check reports of the Investigations Check other records Reports- Confidential No Doctor-Patient relationship established
  31. 31. (1st Page)To, ------------,Dear Sir, Mr./ Mrs. ------- attended my clinic on-------- at - -------a.m./ p.m. for the medical examination & opinion, as per your letter dated -------. His/ Her report is attached here with.Identification marks-(i) ------- (ii)-------Signature of Mr./Mrs./Ms. Signature of Doctor/Lt. Hand Thumb Impression Date- Time-
  32. 32. 2nd ( Page)Your Report ( Confidential) Refer Textbooks/ Consultants in the field, if in doubt Carbon Copy
  33. 33. Supreme Court JudgmentRecord all injuries Sites Type Length etcDo not Omit any injury/ See Back of the patient alsoTreat – First AidRecord the Treatment GivenIf asked to give a letter / Cert. mention all injuries
  34. 34.  Identification Marks of the Patient Signature/ Lt. Hand Thumb Impression Case Paper Record- Name address of the person bringing the patient Refer to hospital if required Take signature/ Lt. Hand thumb Impression of the patient on the referral letter Put the Date and Time on the referral Letter If Ref. to the Hospital on Phone : *Record Name of the Person with whom you talked *Time & Date
  35. 35.  SPECIFICFORMS – L.I.C. NO DOCTOR-PATIENT RELATIONSHIP
  36. 36.  Only on Medical Ground Never issue False Certificate Only in Legitimate Cases Mention a Provisional Diagnosis & expected Investigations and approximate cost of Investigations & treatment Identification Marks of the Patient Signature & Lt. Hand thumb impression of the Patient Doctor’s Signature with Date & Time Carbon Copy
  37. 37.  Examine the person. See the back side of the person Confirm Death Standard Forms supplied by P.M.C. Single Copy Get necessary information from near relative or responsible person in writing
  38. 38.  The dead person must be under care for at least 14 days prior to the Death. Give the Certificate to near relative or close person & take his signature. Do not Issue D.C. if the Death is due to unnatural case. Inform Police. No Fees Xerox Copy of the Certificate
  39. 39. REFUSE D.C. WHEN— M.L.C. Unknown Person Person not under your Care Sudden death in a married lady, within 7 years from the date of her marriage Death due to administration of Injection--- Anaphylaxis
  40. 40.  On Letter Pad For investigaions/Consultation/Admission Clear Instructions Carbon Copy should be kept. Put Date and time at time of Transfer. Write treatment summary & Your assessment of patients condition.
  41. 41.  Receipts & Payments Bills, Invoices,Vouchers Duties &Taxes
  42. 42.  Essentials of a valid consent Free consent- without coercion, undue influence, misrepresentation, fraud or mistake. Capacity to enter contract Adult of sound mind -Minor- by guardian Child -7 to 12 years ????
  43. 43.  Valid consent • Competent person • Major / guardian • Child 7—12 yrs Witnesses — 2 Simple / any language / specific / clear / unambiguous Mention common complications / alternatives In emergency... Sterilisation / castration — both spouses Amputation — second opinion
  44. 44. CONSENT Written consent OR Implied consent Informed consent relevant information of illness and treatment has to be explained Significant material risk has to be explained Alternative modalities Unusual or special risks may not be explained Exceeding consent-- Think of Postponement , Operate only if urgent
  45. 45.  Why doctor should feel shy of informing & taking written statement to that effect? BOLDLY document the non-compliance of any of your advice Consent of a child after (7) 12 years is a must, along with Guardian’s.
  46. 46.  Preservation M.L.C. s ----- for ever ( 30 years ) Administrative papers -- Registers etc 10 years Indoor ----- 5 Years O.P.D. ----- 3 Years Identification Mark on paper is important
  47. 47. Whose Property -Hospital has right over papers butShould provide copy to court / police on demand OTHERWISEIt is a confidential communication andcannot be released without his permission
  48. 48.  Patient has a right to demand it at a reasonable fees and in reasonable time. DONOT SAY NO TO THE DEMAND
  49. 49.  Short history, clinical notes, summary of operation and/or treatment. Instruction on discharge card HAVE to be more elaborate. Always write to report back date --- etc OR report if----

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