documentation for medical students

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DOCUMENTATION ARCHIVING & PAPER PRESENTATION Balasubramanian Thiagarajan

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This presentation discusses various medical documentation methods

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Page 1: Documentation for medical students

DOCUMENTATION ARCHIVING & PAPER PRESENTATIONBalasubramanian Thiagarajan

Page 2: Documentation for medical students

WHY THIS PROGRAMME?

• You are our tomorrow

• You are our front end

• I assume you are all trainable

Lets make knowledge freely available

Page 3: Documentation for medical students

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

Page 4: Documentation for medical students

TYPES OF DOCUMENTATION

• Classic manual method

• Electronic method

• A combination of both

Lives depend on you filling up the pt record accurately and legibly

Page 5: Documentation for medical students

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

Page 6: Documentation for medical students

ELECTRONIC METHOD

• Ideal

• Easy to archive and retrieve

• Paperless

• Data base can be easily accessed and quried

Page 7: Documentation for medical students

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.

Page 8: Documentation for medical students

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

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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

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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

Page 12: Documentation for medical students

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

Page 13: Documentation for medical students

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

Page 14: Documentation for medical students

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

Page 15: Documentation for medical students

ROLE OF RESIDENTS

• Seeing

• Observing

• Learning

• Documenting

Page 16: Documentation for medical students

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

Page 17: Documentation for medical students

drtbalu

TOOLS NEEDED

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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

Page 19: Documentation for medical students

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

Page 20: Documentation for medical students

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

Page 21: Documentation for medical students

TYPES OF HANDY CAM RECORDING MEDIA

• Tape (analog recording)

• DVD / Mini DV

• Hard disk

• SD card

• Flash memory

Page 22: Documentation for medical students

CAMCORDER PORTS

• USB

• Fire wire

• AV in

• AV out

• Power in

• S video

• HDMI

Page 23: Documentation for medical students

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)

Page 24: Documentation for medical students

ARCHIVING OPTIONS

• Picassa

• Skydrive

• Drop box

• Box

• Pen drive

• CD / DVD

• Removable hard drives

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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

Page 32: Documentation for medical students

PNG

• Portable network graphic format

• Suffers no data loss when compressed

• Highly suitable for web display

Page 33: Documentation for medical students

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

Page 37: Documentation for medical students

VIDEO INTERFACES

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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

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PUBLISHING AVENUES

• Journals

• Online sites

• Websites

• Word press blog can be converted to host scholarly articles

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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

Page 43: Documentation for medical students

ONLINE JOURNALS

• Free to publish

• Available online

• Indexed

• Easy online submission

Page 44: Documentation for medical students

INDEXING

Page 45: Documentation for medical students

E BOOK PUBLISHING SERVICES

• Kindle

• Create space

• Otolaryngology e book publishing services

• Open library

Page 46: Documentation for medical students

Thank you