Documentation for medical students
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This document discusses documentation in medicine, including why it is important, different documentation methods, challenges with current systems, and the ideal documentation scenario. It covers topics like the importance of accurate documentation for patient care, types of documentation methods (classic manual, electronic, and combinations), challenges like low rates of accurate and submitted documentation currently, and features of ideal documentation like timely admission slips and discharge summaries entered into electronic patient databases.
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Documentation for medical students
- 1. DOCUMENTATION ARCHIVING & PAPER PRESENTATION Balasubramanian Thiagarajan
- 2. WHY THIS PROGRAMME? • You are our tomorrow • You are our front end • I assume you are all trainable Lets make knowledge freely available
- 3. 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
- 4. TYPES OF DOCUMENTATION • Classic manual method • Electronic method • A combination of both Lives depend on you filling up the pt record accurately and legibly
- 5. CLASSIC MANUAL METHOD • Cumbersome • Difficult to archive and retrieve • May be damaged in course of time • Difficult to decipher Flow of knowledge should not be at a price
- 6. ELECTRONIC METHOD • Ideal • Easy to archive and retrieve • Paperless • Data base can be easily accessed and quried
- 7. 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.
- 8. IMPACT OF GOOD DOCUMENTATION • Patient care and clinical outcomes • Physician to physician communication • To the betterment of health care system Lets be committed to free access of educational resources
- 10. 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
- 11. 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
- 12. 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
- 13. 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 Now it is my turn to give back to the society which has enriched me
- 14. 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
- 15. ROLE OF RESIDENTS • Seeing • Observing • Learning • Documenting
- 16. 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
- 18. FEATURES OF A GOOD DIGITAL CAMERA • Should have high optical zoom • Should be able to shoot in raw mode • A 5 megapixel camera would do. Higher pixel size will consume more space • Should have inbuilt image stabilization feature • Should have a fairly big and good preview screen
- 19. CONTD • Red eye reduction is a useful feature • Multipoint autofocus is a useful feature • Should have the ability to shoot in macro mode • Should have manual ISO setting. Low ISO setting will reduce noise in a photograph taken in good lighting. If the lighting is poor then the settings need to be increased
- 20. HANDY CAM • Currently replacing low end digital cameras • Should be able to record 1080p (progressive video rather than 1080i interlaced video) • Should have a good reach at least 12x optical zoom • It should have a sensor at least 1/3 of an inch. • It should be compact
- 21. TYPES OF HANDY CAM RECORDING MEDIA • Tape (analog recording) • DVD / Mini DV • Hard disk • SD card • Flash memory
- 22. CAMCORDER PORTS • USB • Fire wire • AV in • AV out • Power in • S video • HDMI
- 23. TYPES OF VIDEO EDITING SOFTWARE BUNDLED WITH THE CAMERA • Pinnacle • Vegas pro • Windows movie maker • Adobe premiere • U lead • I movie (apple) • Final cut pro (apple)
- 24. ARCHIVING OPTIONS • Picassa • Skydrive • Drop box • Box • Pen drive • CD / DVD • Removable hard drives
- 25. BEST ARCHIVING PRACTICES • Each of the archived material should be organized inside a folder • Accepted archival norms should be followed • Archiving should be done in removable media and online sites • Images ideally should be archived in raw format
- 26. drtbalu IMAGE FORMATS • BMP (Bitmap) • JPEG (Good for photographs) • PNG Portable network graphics Good for icons) • GIF (Graphic interchange format) • DICOM (Digital imaging and communications in medicine) • TIFF (Images for printing)
- 27. drtbalu IMAGE EDITORS • Photoshop • Acdsee • Corel paintshop • GIMP • Irfan view
- 28. drtbalu BMP 152 kb JPEG 28 kb PNG 8 kb GIFF 12 kb
- 29. drtbalu JPEG • Use this for photographs • Don’t edit an already edited JPEG file • Optimize the size of the image for web viewing • If you have to put multiple JPEG images in a single page put a smaller version giving the option of downloading the larger file to the viewer
- 30. drtbalu DICOM • Standard for handling medical imaging • This image format contains also pt details for easy archiving • It needs a special viewer to view it • Image J is the commonly used viewer to view these files
- 32. PNG • Portable network graphic format • Suffers no data loss when compressed • Highly suitable for web display
- 33. BMP • Bit map format • These images can be stored independently of display device • Can be used in web • Commonly used in windows operating system
- 34. drtbalu RECORDING ENDOSCOPIC SURGERY • Using Handy cam • Using laptop / computer – video capture card
- 35. drtbalu
- 36. drtbalu TYPES OF CABLES • S video cable • Composite cable • HDMI cable
- 37. VIDEO INTERFACES
- 38. WHY SHOULD ONE PUBLISH ? • Mandated by University • Helps during promotions • Sharing one’s experience with others • Getting recognized by peers • Showcasing one’s ability
- 39. drtbalu THE HURDLES • Editor • Editorial Board • Publishing Board • Financial Proforma • Publisher
- 40. PUBLISHING AVENUES • Journals • Online sites • Websites • Word press blog can be converted to host scholarly articles
- 42. REPOSITORIES • A collection of scholarly publications • Universities should strive to maintain them • Our university does not have an on line repository • These repositories should be OAI compliant
- 43. ONLINE JOURNALS • Free to publish • Available online • Indexed • Easy online submission
- 44. INDEXING
- 45. E BOOK PUBLISHING SERVICES • Kindle • Create space • Otolaryngology e book publishing services • Open library