SlideShare verwendet Cookies, um die Funktionalität und Leistungsfähigkeit der Webseite zu verbessern und Ihnen relevante Werbung bereitzustellen. Wenn Sie diese Webseite weiter besuchen, erklären Sie sich mit der Verwendung von Cookies auf dieser Seite einverstanden. Lesen Sie bitte unsere Nutzervereinbarung und die Datenschutzrichtlinie.
SlideShare verwendet Cookies, um die Funktionalität und Leistungsfähigkeit der Webseite zu verbessern und Ihnen relevante Werbung bereitzustellen. Wenn Sie diese Webseite weiter besuchen, erklären Sie sich mit der Verwendung von Cookies auf dieser Seite einverstanden. Lesen Sie bitte unsere unsere Datenschutzrichtlinie und die Nutzervereinbarung.
III C RegisterCase papersPrescriptionsLegal DocumentsCertificatesReferral LettersAccounts
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 LAW2. I.P.C.- SEC.-197 - SEC.- 4633. I.M.C.4. CIVIL SUIT FOR COMPENSATION
1. LETTER HEAD2. RELEVANT INFORMATION3. TRUE STATEMENTS4. DATE & TIME OF ISSUING CERTIFICATES5. IDENTIFICATION MARKS OF PATIENT6. SIGNATURE & /OR LT. HAND THUMB IMPRESSION7. CARBON COPY8. CAN CHARGE EXCEPT DEATH CERT
9. CERTIFYING LT. HAND THUMB IMPRESSION10. CERT. FOR OPINION IN CASE THE PATIENT IS REFERRED FOR MEDICAL OPINION11. CERTIFICATE OF INJURY12. CERT. FOR L.I.C. POLICY13. CERTIFICATE FOR WITHDRAWING MONEY FROM PROVIDENT FUND14. DEATH CERIFICATE
1. RESPONSIBILITY OF DOCTORS/ HOSPITAL2. INFORMATION IN WRITING FROM FATHER & MOTHER OF THE CHILD WITH THEIR SIGNATURES.3. OFFENCE IF NOT REGISTERED.
1. NO BACKDATED CERTIFICATE2. PREPARE A CASE PAPER3. CERTIFY ONLY WHEN UNDER YOUR CARE4. SHOULD INCLUDE- a. Nature of Illness b. Approximate Period for Treatment5. IDENTIFICATION MARKS6. SIGNATURE OR LT. HAND THUMB IMPRESSION OF THE PATIENT
7. DOCTOR’S SIGNATURE,DATE & TIME8. Carbon Copy9. 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.-----Identification marks-(i) ------- (ii)-------Signature of Mr./Mrs./Ms. Signature of Doctor Date- Time-
CERTIFY ONLY WHEN YOU HAVE VACCINATED NO FALSE CERTIFICATE MENTION :-1. Name of Vaccine Administered2. Name of the Manufacturing Pharma Co.3. Batch No.4. Mfg. Date5. Exp. Date6. 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 Person2. Age3. Address4. Place Where the Cert. is Issued5. Date & Time6. 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. Identification marks-(i) ------- (ii)-------Signature of Mr./Mrs./Ms. Signature of Doctor/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.Identification marks-(i) ------- (ii)-------Signature of Mr./Mrs./Ms. Signature of Doctor/Lt. Hand Thumb Impression Date- Time- 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.Identification marks-(i) ------- (ii)-------Signature of Mr./Mrs./Ms. Signature of Doctor/Lt. Hand Thumb Impression Date- Time-
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.Identification marks-(i) ------- (ii)-------Signature of Mr./Mrs./Ms. Signature of Doctor/Lt. Hand Thumb Impression Date- Time- 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 DoctorDate- Time- Seal
GIVEN IN CASE THE PATIENT IS REFERREDFOR 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.Identification marks-(i) ------- (ii)-------Signature of Mr./Mrs./Ms. Signature of Doctor/Lt. Hand Thumb Impression Date- Time-
2nd ( Page)Your Report ( Confidential) Refer Textbooks/ Consultants in the field, if in doubt Carbon Copy
Supreme Court JudgmentRecord all injuries Sites Type Length etcDo not Omit any injury/ See Back of the patient alsoTreat – First AidRecord the Treatment GivenIf asked to give a letter / Cert. mention all injuries
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
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 Identification Marks of the Patient 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.
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 butShould provide copy to court / police on demand OTHERWISEIt is a confidential communication andcannot 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----