The document outlines essential practices for medical documentation, emphasizing the importance of accurate and timely record-keeping to ensure legal protection and effective patient care. It covers critical aspects such as ownership of medical records, the retention period for various types of records, necessary documentation processes, and the appropriate way to communicate death to relatives. Additionally, it highlights the role of clinical judgment and patient participation in care as pivotal components of quality documentation.

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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