Essential Medical Documentation

 Medical Council
 Criminal Court
 Civil Court
 Consumer Redressal Forum
 Janata Durbar! (most dreaded)

III
C Register
Case papers
Prescriptions
Legal Documents
Certificates
Referral Letters
Accounts

 Date
 Sr.No.
 Patient’s Name in Full
 Diagnosis
 Treatment (Service given)
 Fees
 Balance

 Sr. No.
 Full Name
 Full Address
 Contact Number
 Age
 Sex
 Clinical Notes
 Treatment
 Other Details

 A4 or may be smaller
 Your name
 Degree
 Registration No.
 Clinic Address
 Contact Numbers
 Email ( Optional)
 Clinic Times & Weekly Off Day (Optional)

 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

 THISIS THE SIMPLEST FORM OF
DOCUMENTARY EVIDENCE & MAY
PERTAIN TO SUCH FACTS AS –
 BIRTH
 SICKNESS
 COMPENSATION
 VACCINATION
 DEATH

1. COURT OF LAW
2. I.P.C.- SEC.-197
- SEC.- 463
3. I.M.C.
4. CIVIL SUIT FOR COMPENSATION

1. LETTER HEAD
2. RELEVANT INFORMATION
3. TRUE STATEMENTS
4. DATE & TIME OF ISSUING CERTIFICATES
5. IDENTIFICATION MARKS OF PATIENT
6. SIGNATURE & /OR LT. HAND THUMB
IMPRESSION
7. CARBON COPY
8. CAN CHARGE EXCEPT DEATH CERT

1. BIRTH CERTIFICATE
2. SICKNESS CERTIFICATE
3. FITNESS CERTIFICATE
4. VACCINATION CERTIFICATE
5. CERTIFICATE ON WILL
6. MENTAL FITNESS CERTIFICATE
7. DOMICILLIARY TREATMENT CERT.
8. LIFE CERTIFICATE

9. CERTIFYING LT. HAND THUMB
IMPRESSION
10. CERT. FOR OPINION IN CASE THE
PATIENT IS REFERRED FOR MEDICAL
OPINION
11. CERTIFICATE OF INJURY
12. CERT. FOR L.I.C. POLICY
13. CERTIFICATE FOR WITHDRAWING
MONEY FROM PROVIDENT FUND
14. DEATH CERIFICATE

1. RESPONSIBILITY OF DOCTORS/
HOSPITAL
2. INFORMATION IN WRITING FROM
FATHER & MOTHER OF THE CHILD WITH
THEIR SIGNATURES.
3. OFFENCE IF NOT REGISTERED.

1. NO BACKDATED CERTIFICATE
2. PREPARE A CASE PAPER
3. CERTIFY ONLY WHEN UNDER YOUR CARE
4. SHOULD INCLUDE-
a. Nature of Illness
b. Approximate Period for
Treatment
5. IDENTIFICATION MARKS
6. SIGNATURE OR LT. HAND THUMB IMPRESSION OF
THE PATIENT

7. DOCTOR’S SIGNATURE,DATE & TIME
8. Carbon Copy
9. TREATMENT PERIOD PROPORTIONATE TO
THE ILLNESS

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-

 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

 Record Your Observation of Medical
Examination
 Keep a Carbon Copy

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.-----

(ii)-------

Date- Time-

 CERTIFY ONLY WHEN YOU HAVE
VACCINATED
 NO FALSE CERTIFICATE
 MENTION :-
1. Name of Vaccine Administered
2. Name of the Manufacturing Pharma Co.
3. Batch No.
4. Mfg. Date
5. Exp. Date
6. Date & time of Administration

 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

 Examination of the Person
 Case Paper
 Records in Diary:-
1. Name of the Person
2. Age
3. Address
4. Place Where the Cert. is Issued
5. Date & Time
6. Case Paper No.
7. Findings in Diary

 Preserve the Diary FOREVER
 Signature of the Person
 Signature of the Doctor, Date, Time & Seal

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.

(ii)-------

/Lt. Hand Thumb Impression Date- Time-
Seal

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.
(ii)-------

Seal

 EXAMINATION
 CHECKING & VARIFYING OF DOCUMENTS
 XEROX COPIES OF THE DOCUMENTS
 SATISFY ABOUT
i. DIAGNOSIS
ii. TREATMENT

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.
(ii)-------


 Why is it required?
 Examination of the person
 Carbon Copy

This to certify that, I have examined Mr.
Mrs.-------- today. He/She is alive today on -------
at ----------a.m./p. m.

(ii)-------

SEAL

 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 Doctor
Date- Time-
Seal

GIVEN IN CASE THE PATIENT IS REFERRED
FOR 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

(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.
(ii)-------

2nd ( Page)
Your Report ( Confidential)
 Refer Textbooks/ Consultants in the field, if in
doubt
 Carbon Copy

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

 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

 SPECIFICFORMS – L.I.C.
 NO DOCTOR-PATIENT
RELATIONSHIP

 Only on Medical Ground
 Never issue False Certificate
 Only in Legitimate Cases
 Mention a Provisional Diagnosis & expected
Investigations and approximate cost of
Investigations & treatment
 Signature & Lt. Hand thumb impression of the
Patient
 Doctor’s Signature with Date & Time
 Carbon Copy

 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

 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

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

 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.

 Receipts & Payments
 Bills, Invoices,Vouchers
 Duties &Taxes

 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 ????

 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

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

 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.

 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

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

 Patient
has a right to
demand it at a
reasonable fees and in
reasonable time.

 DONOT SAY NO TO
THE DEMAND

 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----

Essential Medical Documentation

Essential Medical Documentation

Essential Medical Documentation

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Essential Medical Documentation