Initial Medical Assessment of the patient within a defined time frame, with complete documentation of all the parameters.
To ensure discussion of Initial Medical Assessment with the Primary Consultant at get it endorsed by him within 24 hours of admission.
Appropriate documentation of Medication Administration Record (MAR).
Appropriate handover to the floor Doctors during shift change,In person.
Verbal order should be restricted only for life-threatening situations and should be documented as soon as the life threatening condition disappears.
All patient care and treatment order should be duty signed & named with date & time (SNDT).
To inform primary consultant after new admission or when shifted in the ward or transfer.
There should be at least two notes for re-assessment every shift once in the beginning and once at the end of the duty hours plus SOS.
Critical results must be collected, documented, with immediate clinical action and appropriate dissemination to consultant.
In case of cardiac arrest, the floor Doctor will initiate CPR/RRT immediately and activate, Code Blue.
Discharge summaries should be documented appropriately and explained to the patient/attendant. It is a medical legal document.
In case of LAMA, Doctors should explain the consequences of being discharged against Medical Advice.
Blood Transfusion note should be documented and in case of transfusion reaction appropriate protocol for reaction should be followed.
Informed consent should be taken prior to HIV Testing and all other procedures.
Should ensure confidentiality & Privacy of the patients.
Should proactively disseminate patient & family education.
In case of MLC, Police information should be given.
In case of death summary cause of death must be mentioned appropriately.
Should attend Basic Life Support (BLS) training as and when organized.
Should attend Quality improvement training session to improve the quality of patient care.
Post Discharge clinical feedback calls will need to be taken instructed by management.
It is responsibility of residents to be available on the floors during working shift.
Resident may be required to accompany patient for a referral transfer/ investigation inside outside the hospital.
All post-op patients and ICU patients shall be reviewed by residents within one hour of step down to words.
It is the responsibility of residents to information referring Doctors of the patients condition and disease in case of a referral. Referreal forms to be filled by resident detailed reason and condition of patient.