1. DOCUMENTATION FOR MEDICAL STUDENTS Balasubramanian Thiagarajan

2. WHY THIS PROGRAMME? You are our tomorrow You are our front end I assume you are all trainable

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. 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.

6. IMPACT OF GOOD DOCUMENTATION Patient care and clinical outcomes Physician to physician communication To the betterment of health care system

8. 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

9. 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

10. 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

11. 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

12. 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

13. ROLE OF INTERNS Seeing Observing Learning Documenting

14. 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

15. CM INSURANCE SCHEME LO DMO Final authorization