Scribd Logo
Upload

Welcome to Scribd!

  • 42 views

    Pointer

    Uploaded by

    Abhishek Kumar
    This document provides important pointers for consultants, medical officers, nursing teams, and PCC/MOD regarding proper documentation procedures. Key requirements include signing and dating all entries in progress notes, consent forms, and the plan of care with name and credentials. Medical officers must ensure all entries in daily progress notes and critical event forms like codes are fully documented. The nursing team must complete assessments and care plans with identifiers. PCC/MOD should ensure bedside procedures are documented and counseling sheets are signed. Proper identification is needed on all documentation to ensure accountability.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Pointer

    Uploaded by

    Abhishek Kumar
    42 views2 pages
    This document provides important pointers for consultants, medical officers, nursing teams, and PCC/MOD regarding proper documentation procedures. Key requirements include signing and dating all entries in progress notes, consent forms, and the plan of care with name and credentials. Medical officers must ensure all entries in daily progress notes and critical event forms like codes are fully documented. The nursing team must complete assessments and care plans with identifiers. PCC/MOD should ensure bedside procedures are documented and counseling sheets are signed. Proper identification is needed on all documentation to ensure accountability.

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides important pointers for consultants, medical officers, nursing teams, and PCC/MOD regarding proper documentation procedures. Key requirements include signing and dating all entries in progress notes, consent forms, and the plan of care with name and credentials. Medical officers must ensure all entries in daily progress notes and critical event forms like codes are fully documented. The nursing team must complete assessments and care plans with identifiers. PCC/MOD should ensure bedside procedures are documented and counseling sheets are signed. Proper identification is needed on all documentation to ensure accountability.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    42 views2 pages

    Pointer

    Uploaded by

    Abhishek Kumar
    This document provides important pointers for consultants, medical officers, nursing teams, and PCC/MOD regarding proper documentation procedures. Key requirements include signing and dating all entries in progress notes, consent forms, and the plan of care with name and credentials. Medical officers must ensure all entries in daily progress notes and critical event forms like codes are fully documented. The nursing team must complete assessments and care plans with identifiers. PCC/MOD should ensure bedside procedures are documented and counseling sheets are signed. Proper identification is needed on all documentation to ensure accountability.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    IMPORTANT POINTER FOR CONSULTANTS:

    1. SIGN, NAME, DATE & TIME WITH ALL ENTRIES IN PROGRESS NOTES

    2. NAME & SIGN ON CONSENT PAPER (SURGICAL, ANESTHESIA, DIALYSIS, CVP,

    VENTILATOR, BLOOD TRANSFUSION)

    3. ISSUE DISCUSSED: SHOULD BE MARK ON ICU FAMILY COUNSELING FORM WITH

    SIGN.

    4. PLAN OF CARE COUNTERSIGNED & POSSIBLE OUTCOME (PLAN OF CARE)

    5. PRIMARY CONSULTANT SHOULD SIGN THE DEATH SUMMARY

    6. CAPITAL PRESCRIPTION OF MEDICATION ON OPD AND IPD FILES

    7. ONLY APPROVED ABBREIATIONS NEED TO MARK ON THE IPD FILES / OPD

    PRESCRIPTIONS.

    IMPORTANT POINTER FOR MEDICAL OFFICERS:

     ALL ENTRIES IN DAILY PROGRESS NOTES WITH SNDT (SIGN, NAME, DATE & TIME)

     POSSIBLE OUTCOMES SHOULD BE DOCUMENTED BY THE CONSULTANT / MO ON THE PLAN OF


    CARE SHEET WITH NAME & SIGNATURE
     ALL CPR NOTES SHOULD BE PROPERLY DOCUMENTED WITH SNDT

     CODE BLUE & RRT FORMS MUST BE FILLING IF CODE ANNOUNCED. CODE BLUE FOMS NOT
    APPLICABLE FOR ICU.
     NAME & SIGN ON CVP CONSENT, VENTILATOR, HIGH RISK, BLOOD TRANSFUSION, PROCEDURE
    CONSENT
     SOFA / APACHE SCORE IS NOT IN PRACTICE FOR ICU PATIENTS

     HANDOVER DOCUMENTATION AT ICU AND FLOOR

    Pls follow the same in the Patient Files by NURSING Team:


    1. Nursing Initial assessment completion with Name / Sign
    2. Nursing care plan documentation
    3. Nursing Supervisors name / sign / Emp.ID in certain form
    4. ICU flow sheet with Name / Sign / Emp. ID
    5. Name / Sign on all Consent form witness
    6. Not using of any blank sheet
    7. ICU admission Criteria at ER & Discharge Criteria from ICU
    8. ICU admission consent with witness Name / Sign at ER (should take responsibility to get it
    filled by MO)

    PCC / MOD:
     Bed side procedure completion
     Ward secretary name / sign on reference sheet
     Not proper stamp on files
     ICU counselling sheet should sign by the consultant while doing

    You might also like