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by Dr Mohammad Aslam

Medical Documentation

Document
Any matter expressed or described upon any substance by means of letter, figure or marks or by 
more than one of these means, which maybe used as evidence of that matter.

· Preparation of Medical document is an important duty of Medical Practitioner.
· Preparation of Medical record concerning patient as Case note, day book, data register.
· Issuing of important Medical document like medical certificate, report, notification to patient, 
colleague and other Administrative Authority like Law court are highly responsible duties.
· Accountability & future planning depends upon their correctness.
· Every country has some kind of system for this purpose but in Pakistan no national Protocol or 
design for preparation of Medical document for guidance of Fresh Medical Practitioner.
· Medical document must have proper structure or format to fulfill the specific objective for 
which it is prepared.
· Absence of standard Protocol leads to inadequate compilation of facts of the case and leads to 
wrong conclusions.

Types of Medical Document
1- Medical Certificate.
2- Medical Report.
3- Medical Notification.
4- Medical Prescription.

Medical Document consists of three portions:
1st & last are common to all documents. 
Ø 1st part for the Identity of the patient.
Ø Last part for the Identity of the Medical Practitioner along with the Registration number of 
PMDC.
Ø Central portion consists of Medical Information relevant to type of document to fulfill the 
specific objective of each document.

1- Medical Certificate
· Complete and fullest Medical information about physical state of individual assessed after his physical and necessary investigations and finally the opinion drawn by the Medical Examiner regarding physical state of health or disease. It starts with “ This is to certify ……… “.
· It is of immense importance to Forensic Medicine. It is prepared in pursuance of law after physical, sexual assaults or intoxication. Such certificates should have additional columns.
Ø Personal Identity of the victim in the observation portion.
Ø Other information like hurt is self inflicted or otherwise in opinion portion.

· It is an open document not confidential.
· Essential of Medical certificate is correctness based on Medical facts or truth.
· If it is wrong ------ damage or penalty.

Example: Sickness, fitness for a job, Medico legal certificate for physical assault, sexual 
assaults, intoxication, postmortem certificate (misnomer for report).

2- Medical Report
· Limited medical information which is prepared and supplied by investigating physician after performing a test upon a part of body of a patient like X-ray, blood, urine, gastric contents & other fluids collected fro the patient.
· This information is necessary for health of patient and for diagnosis of disease of a person. 
Report starts with ‘This is to report…… ‘ and includes only the medical fact elicited by the investigating medical examiner so,
· It is communication between two medical professional (departments).
Ø It is confidential.
Ø It is matter of opinion.
Ø If it s wrong ---- no penalty or damage.

3- Medical Notification
· Medical information of patient who are suffering from either infectious or contagious disease and thus dangerous to other member of society and required urgent medication.
· RMP has a duty to notify such patient to relevant Medical Authority. It starts with ---- ‘ This is to notify….. ‘ and includes only the suspected diagnosis. It matters little whether diagnosis is 
correct or otherwise.
· Duty of RMP is informing the contagious case to EDO (Health) according to MMO1960. 
Examples: Cholera, leprosy, smallpox.
· Medical notification of industrial disease is to be notified to Inspector of factories according to Factory Act 1934.
· Information to be conveyed to the concerned authority with urgency & written with red ink ----- through a special messenger.
· Information may go wrong ---- no penalty.

4- Medical Prescription
· It is direction of Medical Practitioner conveyed to the Pharmacist through the patient for dispensing of Medicine in the way indicated in it.
· It starts with (a symbol) meaning recipe is a prescription.
· Name of medicine --- concentration --- direction of use.
· Prescription of Antibiotic & Dangerous drugs is a privilege of an RMP by Allopathic system (Prevention of Misuse Act 1962).
· Dangerous drugs rules lay an additional duty of writing superscription while prescribing a dangerous drug.
· It is legal duty and should be written carefully.
· The Pharmacist may refuse to dispense the Dangerous drug to the patient without a prescription.

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