The importance & nuances of Documentation in Medical Practice is a concept that medical students in India hardly taught as a part curriculum in India (it was so when I was in med school, the situation has hardly changed based on what current students tell)...1/n

The first brush that Indian medical graduates have with challenges involved in Documentation & protocols as well as liabilities related to them is in Internship (the first few days of the first posting are the hardest) & hence it is important always remember NOT to hesitate & Ask

Always Ask, it is better to not know & learn (even if that means you are risking getting those irritable looks from your seniors).
Asking & learning is better than Not asking & making a mistake & then learning.

If you are going to practice medicine in any part of the world, please remember this bit - "Documentation is the MOST important part of your practice"
"Always Document" "Document correctly" "Document immediately or ASAP in urgent or emergency situations"

"Always Document" all verbal or telephonic orders (especially telephonic or verbal orders) in detail even if it is 4 am in morning, even if it is your HOD. Every DD, Investigation, Drug order (Cross Confirm), Allergy, consent, plan of management, BT notes.

"Document Correctly" has many aspects Date & Time, Your signature, Name of consultant ordering or with whom case has been discussed, the exact orders, Allergies (In Bold Caps), Drugs in Bold, with dosages, frequency, mode of administration, dilutions, specific instructions

When you Document sequence of events after an emergency (even if it is 2 hrs long), make sure to try & document as exact times as you can (ABG/VBG/X-ray time can be of help then) or ask someone in the team to keep a note.

While documenting verbal Drug orders, be sure to inform the consultant about Allergies you have been told, Crosscheck (spelling of drugs/dosages mg vs micrograms) the orders entirely as you document, when taking verbal orders have a Nurse (preferably TL) next to you..

Document the name of TL as well as yourself when you TL down verbal orders. Always write "As discussed with & ordered by so & so in the presence of " Even if your consultant doesn't want you to Document, Always document Drug & investigation orders, past history correctly.

Documentation of Consents should be done properly - "Correct Names" "Diagnosis", "Procedure Name & location", "Never use Abbreviations", "Risks", "High Risks", "Alternatives", "Never Sign a Blank or Incomplete Consent" "In the language of patient"

"Sign with exact date & time", "Get two witnesses to sign - patient & their attendant"
High risks consents should be taken by members of primary team, preferably in detail, in the language of patient & documented with date, time, signatures of both patient & attendant"

"Document immediately or ASAP" in case of all orders (especially verbal or telephonic) because delay causes error & even makes you forget & can also land you in legal mess. If you are over worked ask a colleague or nurse to Document what you dictate, cross check & then sign.

I know Doing this practically can be challenging but if it becomes a part of habit, it isn't a big deal just a bit tiring. I have managed multiple emergencies simultaneously & still managed to do these things no doubt it is challenging in govt set ups due to the volume.

But, trust me Documentation is your only safeguard against being falsely implicated in negligence cases & it is the easiest & most powerful way to ensure Accountability in a system where evading accountability has become a Norm & also ensure Patient safety.

In medico-legal cases, as our legal system operates, documented evidence as a stronger value as compared to any other evidence.
And as medico-legal litigation rises, your habit of documenting will become your strongest friend in the profession.

I have not been exhaustive (like I have not talked about Death Certificates, Discharges etc etc) in this thread but just touched the very basics of Documentation, it is a semester long curriculum & varies a bit with specialities. But its importance is secondary to none.

And NEVEREVER use Abbreviations in a Drug Chart. NEVER. Always cross check doses. Always sign the drug chart. If a drug is stopped, write stop immediately time, by whom & sign. No over writing or cutting & writing in the same line. Laziness in Drug Chart us unforgivable.