Specifically recording return of patient to "normal" from "abnormal"
Following precautions have been advised by the Court:
-Specifically record whenever an abnormality or a patient's complaint or a complication has been addressed and the patient has returned to normalcy.
-In case of post surgery/procedure complications:
Inform the patient about the complication at the earliest and also the remedial measures contemplated. Duly record both.
Advice appropriate investigations at the earliest.
Take specific consent if any surgery/procedure has to be performed.
Duly record if the patient refuses to give consent.
If the patient seeks discharge/transfer, the discharge/transfer note must specifically record the surgery/procedure, the complications, remedial measures taken/advised, refusal of the patient to consent (if any) and the reason/s for the discharge/transfer.
Specifically record whenever an abnormality or a patient's complaint or a complication has been addressed and the patient has returned to normalcy.
-Surgeons must follow proper protocol and check whether clips, etc. are firmly clamped and whether there is any leakage from the operated part, before closing. Leaving loose clips and mistakes of similar nature in performing surgery are negligence per se