The document provides guidance on proper medical record keeping and issuing certificates. It discusses the appropriate format and content for various types of medical certificates including sickness, fitness, vaccination, mental fitness, and death certificates. It emphasizes including accurate patient identification, doctor signature, and other key details. The document also covers maintaining proper clinical records, consent procedures, and preservation of medical documents.
In the presentation efforts have been made to guide the medical professionals how to deal with a MLC case in a step by step manner and certain issues relating to medical case records.
Before the enrollment of a patient in a clinical trial and beginning of any trial-related procedures, an informed consent is obtained from the potential participants. This informed consent form (ICF) provides the participants with the information related to the clinical trial. TSDP provides regulatory medical writing training on preparation of ICF.
How to choose the correct Private Practice & How to be an excellent Practitio...Kusal Goonewardena
Presented by Elite Athlete APA Titled Sports Physiotherapist - Kusal Goonewardena.
With over 15,000 treatment sessions in sports physiotherapy in private practice Kusal Gooonewardena shares
1. How to choose the correct private practice to work in
2. How to become an excellent practitioner when you get there!
Hope you enjoy.
For more information goto www.EliteAkademy.com
In the presentation efforts have been made to guide the medical professionals how to deal with a MLC case in a step by step manner and certain issues relating to medical case records.
Before the enrollment of a patient in a clinical trial and beginning of any trial-related procedures, an informed consent is obtained from the potential participants. This informed consent form (ICF) provides the participants with the information related to the clinical trial. TSDP provides regulatory medical writing training on preparation of ICF.
How to choose the correct Private Practice & How to be an excellent Practitio...Kusal Goonewardena
Presented by Elite Athlete APA Titled Sports Physiotherapist - Kusal Goonewardena.
With over 15,000 treatment sessions in sports physiotherapy in private practice Kusal Gooonewardena shares
1. How to choose the correct private practice to work in
2. How to become an excellent practitioner when you get there!
Hope you enjoy.
For more information goto www.EliteAkademy.com
Is health information always admissible as evidence in court Explai.pdfjeeteshmalani1
Is health information always admissible as evidence in court? Explain your answer and provide
APA references.
Solution
What is one of the most important non-clinical uses of the medical redcord?
It serves as the legal document recording a particular episode of a patient\'s care. (of the facility
and treatment)
When can a patient\'s information be disclosed?
With the written consent or authorization of the patient.
pursuant to statutory requirements or on proper legal process.
Define Evidence
Testimony, writings, material objects, or other things presented to prove or disprove a fact.
Define ADMISSIBLE EVIDENCE
Info. or things that may be admitted as evidence in a trial if the applicable rules establish that the
info. is BOTH PERTINENT and PROPER (timely, accurate, complete records) for the the judge
or jury to consider when deciding issues involved in the lawsuit.
What is HEARSAY?
Out-of-court statements that are offered to prove the truth of the matter asserted. Not signed
under oath.
Why are medical records considered hearsay evidence?
Because the health-care providers making the statements, (entries into the record) do not do so
under oath in a court of law. Therefore under the Hearsay rule they are not admissible as
evidence in court.
So, if Hearsay evidence is not addmisible in court, how can medical records be an exception to
the rule? There ARE exceptions to the rule...
BUSINESS RECORD EXCEPTION to the HEARSAY EXEMPTION RULE specifically allows
medical records to be used as evidence. if the person offering the records can successfully
convince the judge the records are kept in the ordinary course of business and not in preparation
for litigation.
BUSINESS RECORD EXCEPTION to the HEARSAY EXEMPTION RULE
HIM Mgr. / Custodian must establish in court the FOUNDATION and TRUSTWORTHINESS
of their record-keeping.
The three elements of a FOUNDATION REQUIREMENT to the hearsay exemption?
Person submitting the evidence must extablish that the record was;
1. Made and kept in the ordinary course of business
2. recorded at or near the time the event
3. By a person with knowledge of the facts, events, conditions, opinions, or diagnoses appearing
in it.
How is TRUSTWORTHINESS REQUIREMENT to the hearsay exception established?
One of the requirements of the Business Record Exemption to the hearsay rule. HIM/custodian
must testify to:
- Internal policies/procedures governing access to meddical record
- quality control techniques (i.e. corrections & abbreviations of the record)
How does the party wishing to introduce a medical record as evidence establish the accuracy and
trustworthiness of the medical record?
They will bring in the custodian of medical records to testify to the accuracy and trustworthiness
of the records.
How does the Medical Records Custodian testify as to both the foundation and trustworthiness
requirements of the business record exception?
The custodian, the HIM professional, testifies in a trial or deposition:
- To FOUNDATION - testifi.
Procedures in Deathcare Certification within Los Angeles CountyBoard of Rabbis
Powerpoint presentation by Michael Boyko, Hillside Memorial Park and Mortuary. Shown at the April 22, 2010 Funeral Practices Seminar presented by the Board of Rabbis of Southern California and the Jewish Federation of Greater Los Angeles.
Life insurance is a contract between you and the life insurance company (the insurer), which provides you (the assured) or your beneficiary for whose benefit the policy is taken with a pre-determined amount on the happening of a particular event contingent on the duration of human life
Health plus claim intimation form is for Health Insurance Policies (HCB & MSB Claims).Form must be completed & signed by Policy Holder / Principal Insured only and submitted to the TPA.
detail knowledge of medico-legal cases, introduction,types, reports, consent,death certificate, patient right. it will help you to understand the concept of medico-legal cases
Medical records means and includes the record pertaining to the admission, diagnosis, treatment, investigation, daily progress, operations, consultations
Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities.
It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events.
Let us see what Pharmacists, Doctors and Patients can do about it.
Since January 2020 when the 1st Covid case was diagnosed, India was engulfed by the PANDEMIC and all the discrepancies came to Fore. Since Independence all the Govts have totally ignored the Health Sector. Let us hope after 2021 the things will change. Here are some lessons to be learnt.
Telemedicine is being used by many doctors all over India during COVID19 Pandemic. Medical Council has given permission to it. The presentation about the guideline to use Telemedicine by the RMPs in India.
There should be some guidelines for The Telephone Consultation and Online Practice. There were some cases when doctors treated the patient on telephone & were involved in some litigations .
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
3. Date
Sr.No.
Patient’s Name in Full
Diagnosis
Treatment (Service given)
Fees
Balance
4. Sr. No.
Full Name
Full Address
Contact Number
Age
Sex
Clinical Notes
Treatment
Other Details
5. A4 or may be smaller
Your name
Degree
Registration No.
Clinic Address
Contact Numbers
Email ( Optional)
Clinic Times & Weekly Off Day (Optional)
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. THISIS THE SIMPLEST FORM OF
DOCUMENTARY EVIDENCE & MAY
PERTAIN TO SUCH FACTS AS –
BIRTH
SICKNESS
COMPENSATION
VACCINATION
DEATH
8. 1. COURT OF LAW
2. I.P.C.- SEC.-197
- SEC.- 463
3. I.M.C.
4. CIVIL SUIT FOR COMPENSATION
9. 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
10. 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
11. 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
12. 1. RESPONSIBILITY OF DOCTORS/
HOSPITAL
2. INFORMATION IN WRITING FROM
FATHER & MOTHER OF THE CHILD WITH
THEIR SIGNATURES.
3. OFFENCE IF NOT REGISTERED.
13. 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
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. 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. Record Your Observation of Medical
Examination
Keep a Carbon Copy
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. 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
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. 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
22. Preserve the Diary FOREVER
Signature of the Person
Signature of the Doctor, Date, Time & Seal
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. 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. EXAMINATION
CHECKING & VARIFYING OF DOCUMENTS
XEROX COPIES OF THE DOCUMENTS
SATISFY ABOUT
i. DIAGNOSIS
ii. TREATMENT
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. Why is it required?
Examination of the person
Carbon Copy
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. 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
30. 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
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. 2nd ( Page)
Your Report ( Confidential)
Refer Textbooks/ Consultants in the field, if in
doubt
Carbon Copy
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. 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
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. 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. 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. 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. 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.
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. 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. 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. 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. 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. 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. Patient
has a right to
demand it at a
reasonable fees and in
reasonable time.
DONOT SAY NO TO
THE DEMAND
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----