The document provides guidance on proper medical record keeping and issuing certificates. It discusses the appropriate format and content for various types of medical certificates including sickness, fitness, vaccination, mental fitness, and death certificates. It emphasizes including accurate patient identification, doctor signature, and other key details. The document also covers maintaining proper clinical records, consent procedures, and preservation of medical documents.
3. Date
Sr.No.
Patient’s Name in Full
Diagnosis
Treatment (Service given)
Fees
Balance
4. Sr. No.
Full Name
Full Address
Contact Number
Age
Sex
Clinical Notes
Treatment
Other Details
5. A4 or may be smaller
Your name
Degree
Registration No.
Clinic Address
Contact Numbers
Email ( Optional)
Clinic Times & Weekly Off Day (Optional)
6. Preferably in Neat ,Good, Legible hand writing
Drugs in CAPITAL LETTERS
Strength of medicine must be written
Correct dosages With clear instructions of
frequency of intake
On Letter pad or Plain Paper with seal.
Seal must have Name, Degree, Reg.No., Address
Not on Medical Store or paper with Pharma advt
Date, Address and Registration No & proper
signature is must
Preferably give follow up date
7. THISIS THE SIMPLEST FORM OF
DOCUMENTARY EVIDENCE & MAY
PERTAIN TO SUCH FACTS AS –
BIRTH
SICKNESS
COMPENSATION
VACCINATION
DEATH
8. 1. COURT OF LAW
2. I.P.C.- SEC.-197
- SEC.- 463
3. I.M.C.
4. CIVIL SUIT FOR COMPENSATION
9. 1. LETTER HEAD
2. RELEVANT INFORMATION
3. TRUE STATEMENTS
4. DATE & TIME OF ISSUING CERTIFICATES
5. IDENTIFICATION MARKS OF PATIENT
6. SIGNATURE & /OR LT. HAND THUMB
IMPRESSION
7. CARBON COPY
8. CAN CHARGE EXCEPT DEATH CERT
10. 1. BIRTH CERTIFICATE
2. SICKNESS CERTIFICATE
3. FITNESS CERTIFICATE
4. VACCINATION CERTIFICATE
5. CERTIFICATE ON WILL
6. MENTAL FITNESS CERTIFICATE
7. DOMICILLIARY TREATMENT CERT.
8. LIFE CERTIFICATE
11. 9. CERTIFYING LT. HAND THUMB
IMPRESSION
10. CERT. FOR OPINION IN CASE THE
PATIENT IS REFERRED FOR MEDICAL
OPINION
11. CERTIFICATE OF INJURY
12. CERT. FOR L.I.C. POLICY
13. CERTIFICATE FOR WITHDRAWING
MONEY FROM PROVIDENT FUND
14. DEATH CERIFICATE
12. 1. RESPONSIBILITY OF DOCTORS/
HOSPITAL
2. INFORMATION IN WRITING FROM
FATHER & MOTHER OF THE CHILD WITH
THEIR SIGNATURES.
3. OFFENCE IF NOT REGISTERED.
13. 1. NO BACKDATED CERTIFICATE
2. PREPARE A CASE PAPER
3. CERTIFY ONLY WHEN UNDER YOUR CARE
4. SHOULD INCLUDE-
a. Nature of Illness
b. Approximate Period for
Treatment
5. IDENTIFICATION MARKS
6. SIGNATURE OR LT. HAND THUMB IMPRESSION OF
THE PATIENT
15. I, Dr. ------ after careful personal examination, do
hereby certify that Mr./Mrs./Ms……………….(
whose signature is given below is suffering from -----
------
and I consider that a period of absence from duty of
about -----days/weeks is necessary for the restoration
of his/her health with effect from -------.
Identification marks-(i) -------
(ii)-------
Signature of Mr./Mrs./Ms. Signature of Doctor
Date- Time-
16. Recovery after Illness
Consider the purpose for which fitness is
required
Pay Attention to COLOUR VISION
Identification Marks of the Patient
Signature/ Lt. Hand Thumb Impression of the
Patient
Signature of Doctor with Date & Time
17. Record Your Observation of Medical
Examination
Keep a Carbon Copy
18. This is to Certify that, I have examined
Mr./Mrs./Ms. -----------today, (Whose signature is given
below) & find that he/she has recovered from his/ her
illness and in my opinion, is physically fit to resume his/
her duties from today/tomorrow i.e.-----
Identification marks-(i) -------
(ii)-------
Signature of Mr./Mrs./Ms. Signature of Doctor
Date- Time-
19. CERTIFY ONLY WHEN YOU HAVE
VACCINATED
NO FALSE CERTIFICATE
MENTION :-
1. Name of Vaccine Administered
2. Name of the Manufacturing Pharma Co.
3. Batch No.
4. Mfg. Date
5. Exp. Date
6. Date & time of Administration
20. Case Paper
Identification Marks of the Person Vaccinated
Signature/ Lt. Hand Thumb Impression of the
Person Vaccinated
Doctor’s Signature with Date & Time
Carbon Copy
21. Examination of the Person
Case Paper
Records in Diary:-
1. Name of the Person
2. Age
3. Address
4. Place Where the Cert. is Issued
5. Date & Time
6. Case Paper No.
7. Findings in Diary
22. Preserve the Diary FOREVER
Signature of the Person
Signature of the Doctor, Date, Time & Seal
23. This is to Certify that, I have examined Mr./Mrs. ------
--- today. In my opinion, at the time of the examination he/ she is
mentally competent to depose his/her assets and for executing
this document.
Identification marks-(i) -------
(ii)-------
Signature of Mr./Mrs./Ms. Signature of Doctor
/Lt. Hand Thumb Impression Date- Time-
Seal
24. This is to Certify that, I have examined Mr./Mrs. --------- today. In
my opinion, at the time of the examination he/ she is mentally
in a sound condition of health.
Identification marks-(i) -------
(ii)-------
Signature of Mr./Mrs./Ms. Signature of Doctor
/Lt. Hand Thumb Impression Date- Time-
Seal
25. EXAMINATION
CHECKING & VARIFYING OF DOCUMENTS
XEROX COPIES OF THE DOCUMENTS
SATISFY ABOUT
i. DIAGNOSIS
ii. TREATMENT
26. This to certify that I have examined Mr./Mrs. -------- today. After
going through the records of the investigations, other records &
the clinical examination, I am of the opinion Mr./Mrs.------- is
suffering from ------- . He/ She needs domiciliary Treatment for
this condition.
At present, he/she is taking following medicines-------------.
Drugs & doses may change as per the condition that time.
Identification marks-(i) -------
(ii)-------
Signature of Mr./Mrs./Ms. Signature of Doctor
/Lt. Hand Thumb Impression Date- Time-
27. Why is it required?
Examination of the person
Carbon Copy
28. This to certify that, I have examined Mr.
Mrs.-------- today. He/She is alive today on -------
at ----------a.m./p. m.
Identification marks-(i) -------
(ii)-------
Signature of Mr./Mrs./Ms. Signature of Doctor
/Lt. Hand Thumb Impression Date- Time-
SEAL
29. Why is it Required?
To Known person only
Taken on the Bank’s withdrawal Slip- filled in
completely
Thumb Impression in Your Presence
Record in a Diary
FORMAT:
Lt. Hand Thumb Impression of Mr./Mrs. ----------is
taken in My Presence.
Signature of Doctor
Date- Time-
Seal
30. GIVEN IN CASE THE PATIENT IS REFERRED
FOR MEDICAL OPINION.
Why is it required?
Who is expected to do this Medical
Examination?
Examine the Patient
Check reports of the Investigations
Check other records
Reports- Confidential
No Doctor-Patient relationship established
31. (1st Page)
To,
------------,
Dear Sir,
Mr./ Mrs. ------- attended my clinic on-------- at -
-------a.m./ p.m. for the medical examination &
opinion, as per your letter dated -------. His/ Her report is
attached here with.
Identification marks-(i) -------
(ii)-------
Signature of Mr./Mrs./Ms. Signature of Doctor
/Lt. Hand Thumb Impression Date- Time-
32. 2nd ( Page)
Your Report ( Confidential)
Refer Textbooks/ Consultants in the field, if in
doubt
Carbon Copy
33. Supreme Court Judgment
Record all injuries Sites
Type
Length etc
Do not Omit any injury/ See Back of the
patient also
Treat – First Aid
Record the Treatment Given
If asked to give a letter / Cert. mention all
injuries
34. Identification Marks of the Patient
Signature/ Lt. Hand Thumb Impression
Case Paper
Record- Name address of the person bringing
the patient
Refer to hospital if required
Take signature/ Lt. Hand thumb Impression of
the patient on the referral letter
Put the Date and Time on the referral Letter
If Ref. to the Hospital on Phone :
*Record Name of the Person with whom
you talked
*Time & Date
36. Only on Medical Ground
Never issue False Certificate
Only in Legitimate Cases
Mention a Provisional Diagnosis & expected
Investigations and approximate cost of
Investigations & treatment
Identification Marks of the Patient
Signature & Lt. Hand thumb impression of the
Patient
Doctor’s Signature with Date & Time
Carbon Copy
37. Examine the person. See the back side of the
person
Confirm Death
Standard Forms supplied by P.M.C.
Single Copy
Get necessary information from near relative
or responsible person in writing
38. The dead person must be under care for at
least 14 days prior to the Death.
Give the Certificate to near relative or close
person & take his signature.
Do not Issue D.C. if the Death is due to
unnatural case. Inform Police.
No Fees
Xerox Copy of the Certificate
39. REFUSE D.C. WHEN—
M.L.C.
Unknown Person
Person not under your Care
Sudden death in a married lady, within 7 years
from the date of her marriage
Death due to administration of Injection---
Anaphylaxis
40. On Letter Pad
For investigaions/Consultation/Admission
Clear Instructions
Carbon Copy should be kept.
Put Date and time at time of Transfer.
Write treatment summary & Your assessment
of patients condition.
42. Essentials of a valid consent
Free consent- without coercion, undue
influence, misrepresentation, fraud or mistake.
Capacity to enter contract
Adult of sound mind
-Minor- by guardian
Child -7 to 12 years ????
43. Valid consent
• Competent person
• Major / guardian
• Child 7—12 yrs
Witnesses — 2
Simple / any language / specific / clear /
unambiguous
Mention common complications / alternatives
In emergency...
Sterilisation / castration — both spouses
Amputation — second opinion
44. CONSENT
Written consent OR Implied consent
Informed consent relevant information of
illness and treatment has to be explained
Significant material risk has to be explained
Alternative modalities
Unusual or special risks may not be
explained
Exceeding consent-- Think of Postponement
, Operate only if urgent
45. Why doctor should feel shy of informing &
taking written statement to that effect?
BOLDLY document the non-compliance of
any of your advice
Consent of a child after (7) 12 years is a
must, along with Guardian’s.
46. Preservation
M.L.C. s ----- for ever ( 30 years )
Administrative papers -- Registers etc
10 years
Indoor ----- 5 Years
O.P.D. ----- 3 Years
Identification Mark on paper is important
47. Whose Property -
Hospital has right over papers but
Should provide copy to court / police on
demand OTHERWISE
It is a confidential communication and
cannot be released without his
permission
48. Patient
has a right to
demand it at a
reasonable fees and in
reasonable time.
DONOT SAY NO TO
THE DEMAND
49. Short history, clinical notes, summary of
operation and/or treatment.
Instruction on discharge card HAVE to be
more elaborate.
Always write to report back
date --- etc OR
report if----