Discharge Summary: Fill & Download for Free

Your test reports belong to you. By law the hospital has to provide you with a copy of your reports.Not only reports but patients have a right to get a copy of their treatment details and discharge summary as well.You can write a formal letter to the medical superintendent or CEO requesting for a copy of your reports.https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/patients-have-right-to-get-medical-records-from-hospitalssays-law-ministry/articleshow/40588458.cms

Wake up at 6. Get ready by 6.30.Reach the ward by 6.45. Get a coffee on the way first.6.45–8.15. Sampling, discharge summaries, vitals and making sure nothing worsened overnight.8.15–9 Academic class- could be journal club/mortality meet/seminar.9–1.30 OPD1.30- 1.45 find some time for lunch since you haven’t eaten breakfast!1.45- 4.30 Run around for getting USG, CT/ MRI of patients. Complete your clinical notes. Give discharge.4.30- 6 Workup your case/new admission.6–7.30 Evening rounds.7.30- 9.30- Finish pending work.That’s how it has been till now. I usually get free by 9.30. Someday 10.30/11 especially if a patient is sick and needs more frequent monitoring. For eg a DKA patient requiring much more frequent VBG/RBS monitoring.Repeat the above for 7 days. (OPD being replaced with rounds and more work on non OPD days and Yeah- no, Sundays!)

Let me give the answer from a doctors perspective.Although most doctors including me find record keeping boring, it is a vital part of a doctors life.Doctors may end up spending 30-50% of their working hours writing case records or typing them in a computer, writing drug charts, drug indents, insurance forms, discharge summaries and many more essential paper work.Some of the work is duplicated as multiple records are needed to be maintained.Why is it important to maintain recordsRecords are a proof that you have managed the patient properly. There is a saying “If it not recorded, it is not done. “Records provide continuity of care. Doctors and nurses cannot continously work in the hospital, they work in shift and case records help them in guiding a patients treatment by informing them about the patients status over the preceeding hours, days to years.A doctor puts his thoughts and plans in the record. This guides a patients treatment.Obviously in legal problems records are very important. Records that are not signed, dated or have corrections that seem illegal are not valid.Records are important for research. They provide data for doing studies.Records are important for summarizing a patients condition for providing discharge summaries and insurance reports.Records are needed to look at the quantum of work done by the doctor and the department. Future expansion and funding depends on the amount of work you do.Record are needed for the safety of the patient.In high income countries medical transcription and audio recording of notes is common. Although this can be expensive as it requires more staff and technology. Majority of Indian doctors still rely on their mighty pens and unique code words to enter their findings in a case sheet.