v. Case taking/ file Keeping (PAGE 1)
(spoken words fly away, written words remain)Caius Titus
Clinical record keeping is an integral component in good professional practice and the delivery of quality healthcare. Regardless of the form of the records (i.e. electronic or paper), good clinical record keeping should enable continuity of care and should enhance communication between different healthcare professionals. Consequently, clinical records should be updated, where appropriate, by all members of the multidisciplinary team that are involved in a patient’s care (physicians, surgeons, nurses, pharmacists, physiotherapists, occupational therapists, psychologists, chaplains, administrators or students). Should the need arise patients themselves should have access to their records to be able to see what has been done and what has been considered. Clinical records are also valuable documents to audit the quality of healthcare services offered and can also be used for investigating serious incidents, patient complaints and compensation cases. The basic princple of file keeping is that
“the duty to share information can be as important as the duty to protect patient confidentiality”.
The patient files @ ICCONS Tvm are learnt to be kept systematically handwritten in paper and digitalisation is not yet intitated .No models or files or screening tools were made available for our observation or perusal even on request for the purpose of observation as part of this internship on the pretext of maintaining the privacy of the patient.
The files are reported as containing details like present issues or problems,family history,consanguinity(the fact of being descended from the same ancestor.),birth history ( prenatal, perinatal , postnatal ) ,history of past medication, developmental history,fine and gross motor skills,peripheral mechanical examination , comprehension,expression,pragmatics,semantic relations (The study concerned with the relations between signs and their referents; the relations between the signs of a system; and human behavioral reaction to signs, including unconscious attitudes, influences of social institutions, and epistemologic and linguistic assumptions. eg: being fair / just / objective / impartial/ unbiased leap / spring/ bound/ hop/ bounce / debate/discuss/confer about/talk over/talk through/thrash out/argue/dispute/contend over/contest/controvert/ moot peer/colleague/friend & peer/peek/look).
Let me thank ABIDA , a member of our group who collected these details after personal interviews with some of the professionals @ICCONS .
OBSERVATION : Digitalisation of patient files must be inititated without delay.
ABIDAS NOTES
iii. The departments of ICCONS and the facilities
iv. Registration of patients/ cases
vi. Clinical and other examinations
vii. Procedure of Assessment at various departments / tests
viii. Identification of problems/ disorders/ disabilities
ix. Treatment/therapies/interventions and advice
x. Management / Rehabilitation process
xi. The types of cases came on the observation days
xii. The Parents’/ escorts’ roll during and after the treatment sessions
xiii. The improvements of the cases
xiv. The ideas got from the classes of experts and discussions
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