Doctors are for patient’s safety and properly documented medical doctors are for doctor’s safety was the concluding remarks of the JCI team who recently concluded their inspection at Moolchand Medcity.
The importance of timely and accurate documentation cannot be over emphasized.
Imagine you are on the round and you say to your junior that this patient is suffering from a rare fungal brain infection but you fail to document the same. In the evening round your another junior thinks the same but documents it on the record. When the case report is published the name of your junior will be before your name. On paper it will be taken as his research and not yours.
Believe in Jangal Me Mor Nacha Sabne Dekha.
All of us come across lot of instances where we say “didn’t I say this last week what’s new if the politicians are talking about it today”. If you have an idea document it.
In terms of medical records thy can save one from medico legal problems.
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