DOCUMENTATION FOR

MEDICAL STUDENTS
Balasubramanian Thiagarajan
 WHY THIS PROGRAMME?
• You are our tomorrow
• You are our front end
• I assume you are all trainable
 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

 TYPES OF DOCUMENTATION
• Classic manual method
• Electronic method
• A combination of both

Lives depend on you filling up the pt record accurately and legibly

 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.
 IMPACT OF GOOD
DOCUMENTATION
• Patient care and clinical outcomes
• Physician to physician communication
• To the betterment of health care system
 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
 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
 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
 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
 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
 ROLE OF INTERNS
• Seeing
• Observing
• Learning
• Documenting
 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
 CM INSURANCE SCHEME
• LO
• DMO
• Final authorization