Medical Records Completion Guidelines I. Admit Checklist II. Allergies Listed A. H&P sheet 1. Timeliness 2.

History sheet should be completed. If patient has pain, please do the pain scoring. 3. Examination findings should be completed 4. Nutritional screen should be completed by doctors and adequate referrals be send as required 5. Functional screen should be completed by doctors and adequate referrals be send as required 6. Discharge plan should be completed. In cases where discharge plan is superfluous, kindly mention discharge criteria, fulfilling which patient may be discharged. 7. Treatment plan should be completed 8. Legibility kindly write in legible handwriting. 9. Accuracy Wherever you need not write details, use approved abbreviations like No Abnormality Detected (NAD), Not Applicable (N/A) etc. 10. Date written Date your documentation 11. Time written Time has to be documented, it is mandatory. 12. Consultant Sign in History & Physical Form is mandatory. B. Nursing Admission Assessment 1. Timeliness 2. Completeness 3. Legibility C. Consent 1. Completeness Treating physician should obtain consent. Each consent process must involve information about a) the patients condition; b) the proposed treatment(s); c) the name of the person providing the treatment; d) potential benefits and drawbacks; e) possible alternatives; f) the likelihood of success; g) possible problems related to recovery; and h) possible results of non treatment. 2. Legibility 3. Date 4. Sign Consultants signature in consent forms are highly desirable, (exception , General Consent, Blood Transfusion Consent) 5. Witness

D. Nutrition Form A (Dietician) 1. Completeness 2. Legibility 3. Accuracy E. Nutrition Form B (Dietician) 1. Completeness 2. Legibility 3. Accuracy F. In house Transfer Form 1. Medical Reconciliation 2. Completeness 3. Accuracy G. Consultant Referral Form 1. Completeness 2. Date & Time 3. Referral Notes should only be written in the Consultant Referral Form. 4. Consultant Referral Form should be placed alongside the progress note on the date referral was first made. H. Restraint Form 1. Completeness 2. Consent for restraint 3. Type of Restraint 4. Family Educated I. Anesthesia Assessment 1. Completeness 2. Anesthesia Consent Ideally all anesthesia consent shall be documented during the PAC. Consent shall be taken by person conducting PAC 3. Pre-Op Check Documented 4. Pre Operative Vitals Documented 5. Pre induction checklist 6. Operative Anesthesia Records Completion 7. Recovery Room (RR) records have to be completed before the patient is wheeled out of the RR. 8. Consultant Signature, Date & Time are mandatory. J. Operation Theater Record 1. Legibility 2. All sections have to be filled up properly. 3. Please note the Start Time and End Time (Tourniquet Time) wherever applicable. 4. Pre and Post (Peri) Operative Diagnosis (not Histopathology) have to be mentioned 5. Complications or no complications - mention 6. Completed before transfer out of recovery K. Progress Notes Must Do 1. Completeness

2. Legibility 3. Written daily In critical care areas, review patient and document the findings as per the laid down norms in Critical Care Manual 4. Effect of medication shall be documented 5. Pain Assessment Pain assessment shall be done during each assessment of the patient and pain score be documented (e.g. 0/10 for No pain) according to the VAS (Visual Analogue Scale). In any patient, if the pain scores are on or above 3/10; please provide a plan for pain management. 6. Care Plan shall be written at least once in 24 hours 7. Patient education shall be written in the progress note , including education about diagnosis, treatment and outcomes. Must Avoid 1. Avoid writing instructions in the Progress note ( Doctors Instruction Sheet) 2. Avoid writing the Cath Lab, OT & Endoscopy notes in the Progress notes ( separate forms are available for this purposes) 3. Avoid taking consent of patient & patients family member in their handwriting in progress notes. (Is not a necessity in Court of Law) 4. Avoid writing notes in progress notes as a referral physician or consultant. L. Nursing Notes 1. Completeness 2. Legibility 3. Effect of medication 4. Pain Assessment 5. Care plan written M. Blood Transfusion Notes 1. Consent shall be completed 2. Assessment during transfusion done 3. Duration of transfusion mentioned N. Physiotherapy Assessment 1. Completeness 2. Timeliness 3. Accuracy O. Doctors Instruction Sheet 1. ALL non drug orders written here 2. Legibility 3. Orders Dated by doctors 4. Orders Timed by doctors 5. Write verbal reports of the Lab, and Critical Test Results in Critical Test Result reporting form. P. Medication Chart 1. Write Weight, Allergies etc. 2. Legible / Capital Only for the Drug 3. Mention Injection or Oral 4. Mention Dose

5. Mention Route 6. Mention Frequency 7. When a medication has any change in Dose, Route & Frequency, Write STOP , and write a fresh order 8. For STAT and SOS orders, please write when and why it is given. 9. Doctors signature & time is must 10. Nurses signature & time is must on administration 11. Pharmacist should sign following verification of medicines 12. On 4th page, write name and signature Q. IDTR & Patient education sheet 1. Assessment 2. Completeness 3. Timeliness 4. Educate patient and document R. Discharge Checklist Completeness S. Discharge Summary Contents Reason for admission, Significant findings, Any diagnosis, Any procedures performed, Any medication and treatment, Condition upon discharge, Discharge Medication Follow up instructions If applicable, Stop Smoking Counseling 1. Condition of patient documented 2. Intra-hospital medication documented 3. Physical activity advice documented 4. Diet advice documented 5. Other non-drug advice documented 6. Completeness 7. Accuracy