documentation for medical students
DESCRIPTION
This presentation discusses various medical documentation methodsTRANSCRIPT
DOCUMENTATION ARCHIVING & PAPER PRESENTATIONBalasubramanian Thiagarajan
WHY THIS PROGRAMME?
• You are our tomorrow
• You are our front end
• I assume you are all trainable
Lets make knowledge freely available
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
CLASSIC MANUAL METHOD
• Cumbersome
• Difficult to archive and retrieve
• May be damaged in course of time
• Difficult to decipher
Flow of knowledge should not be at a price
ELECTRONIC METHOD
• Ideal
• Easy to archive and retrieve
• Paperless
• Data base can be easily accessed and quried
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
Lets be committed to free access of educational resources
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
Now it is my turn to give back to the society which has enriched me
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 RESIDENTS
• 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
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TOOLS NEEDED
FEATURES OF A GOOD DIGITAL CAMERA
• Should have high optical zoom
• Should be able to shoot in raw mode
• A 5 megapixel camera would do. Higher pixel size will consume more space
• Should have inbuilt image stabilization feature
• Should have a fairly big and good preview screen
CONTD
• Red eye reduction is a useful feature
• Multipoint autofocus is a useful feature
• Should have the ability to shoot in macro mode
• Should have manual ISO setting. Low ISO setting will reduce noise in a photograph taken in good lighting. If the lighting is poor then the settings need to be increased
HANDY CAM
• Currently replacing low end digital cameras
• Should be able to record 1080p (progressive video rather than 1080i interlaced video)
• Should have a good reach at least 12x optical zoom
• It should have a sensor at least 1/3 of an inch.
• It should be compact
TYPES OF HANDY CAM RECORDING MEDIA
• Tape (analog recording)
• DVD / Mini DV
• Hard disk
• SD card
• Flash memory
CAMCORDER PORTS
• USB
• Fire wire
• AV in
• AV out
• Power in
• S video
• HDMI
TYPES OF VIDEO EDITING SOFTWARE BUNDLED WITH THE CAMERA
• Pinnacle
• Vegas pro
• Windows movie maker
• Adobe premiere
• U lead
• I movie (apple)
• Final cut pro (apple)
ARCHIVING OPTIONS
• Picassa
• Skydrive
• Drop box
• Box
• Pen drive
• CD / DVD
• Removable hard drives
BEST ARCHIVING PRACTICES
• Each of the archived material should be organized inside a folder
• Accepted archival norms should be followed
• Archiving should be done in removable media and online sites
• Images ideally should be archived in raw format
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IMAGE FORMATS• BMP (Bitmap)• JPEG (Good for photographs)• PNG Portable network graphics Good for
icons)• GIF (Graphic interchange format)• DICOM (Digital imaging and
communications in medicine)• TIFF (Images for printing)
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IMAGE EDITORS
• Photoshop
• Acdsee
• Corel paintshop
• GIMP
• Irfan view
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BMP 152 kb JPEG 28 kb
PNG 8 kb
GIFF 12 kb
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JPEG
• Use this for photographs
• Don’t edit an already edited JPEG file
• Optimize the size of the image for web viewing
• If you have to put multiple JPEG images in a single page put a smaller version giving the option of downloading the larger file to the viewer
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DICOM
• Standard for handling medical imaging
• This image format contains also pt details for easy archiving
• It needs a special viewer to view it
• Image J is the commonly used viewer to view these files
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DICOM CONVERTERS
PNG
• Portable network graphic format
• Suffers no data loss when compressed
• Highly suitable for web display
BMP
• Bit map format
• These images can be stored independently of display device
• Can be used in web
• Commonly used in windows operating system
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RECORDING ENDOSCOPIC SURGERY
• Using Handy cam
• Using laptop / computer – video capture card
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TYPES OF CABLES
• S video cable
• Composite cable
• HDMI cable
VIDEO INTERFACES
WHY SHOULD ONE PUBLISH ?
• Mandated by University
• Helps during promotions
• Sharing one’s experience with others
• Getting recognized by peers
• Showcasing one’s ability
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THE HURDLES
• Editor• Editorial Board• Publishing Board• Financial Proforma• Publisher
PUBLISHING AVENUES
• Journals
• Online sites
• Websites
• Word press blog can be converted to host scholarly articles
REPOSITORIES
• A collection of scholarly publications
• Universities should strive to maintain them
• Our university does not have an on line repository
• These repositories should be OAI compliant
ONLINE JOURNALS
• Free to publish
• Available online
• Indexed
• Easy online submission
INDEXING
E BOOK PUBLISHING SERVICES
• Kindle
• Create space
• Otolaryngology e book publishing services
• Open library
Thank you