Resident Medical Officer

You are responsible for providing medical care and maintaining medical records under instructions and supervision of Consultant/s.
- Examine all newly admitted patients as soon as possible in the wards / ICU.
- You should familiarize yourself with wards, bed categories, distributions, admission and discharge procedures.
- Prescribe and provide appropriate treatment under instructions of the Consultant, promptly with least delays.
- Maintain detailed accurate written records of clinical history, instructions received from the Consultant, Progress Notes, Onset of Complications, Investigations and Operative Procedures Discharge Summaries and Instructions.
- Give written instructions regarding investigations to the Nursing Staff and ensure that all investigative procedures are carried out expeditiously and results obtained promptly and conveyed to the concerned consultant at the earliest opportunity.
- Review all prescriptions on a regular basis, to avoid unnecessary and/or overlapping medication.
- Conduct wards rounds with the Consultant in charge of the patients.
- Check with patients and nursing staff to ensure that instructions given and prescribed treatment are actually carried out.
- Not leave the duty / Hospital premises when on duty, without prior permission from the HR/ Hospital Administrator.
- Assist the consultants in conducting in Outpatient Clinics.
- You should inform the patient verbally about investigative/operative procedure/s to be performed, and obtain a written consent in the prescribed format. The consent form should be signed and dated by the patient / legal guardian. Consent form is an important part of medical records.

**Emergency Care**
- Examine patients reporting for emergency treatment if called to do so.
- Provide emergency care on outpatient basis if they do not require admission as and when required.
- Maintain detailed and accurate medical records for the emergency medical care provide, as these may be required for medico-legal purpose later on.

**Discharges**
- The patients should be advised about the likely time of their discharge in advance and preferably a day earlier once get confirmation from concern consultant.
- Record detailed discharge notes on the case paper, and also provides the patient with an e-discharge summary and treatment summary and treatment note.
- Advise the relative to contact the billing department & nursing staff well & advance to avoid delays and difficulties in completing discharge procedure.
- Provide advance information to the Billing Department about impending discharges, so that bills can be presented on time.
- **e
- Discharge Card**:

- You will be given Login ID by HR & Admin Dept. 'e'discharge Summary is to be given to patients. You have to check all the entries before signing the discharge card. The duplicate copy of the same is to be kept in the patient's file. Ensure that the e - discharge card is given to the patient promptly once the consultant declares that the patient is fit for discharge. After signing the discharge card you have to write your full name below the signature.

**Medical Records**
- 'Accurate detailed medical records are the only 'protection against any problems arising out of Consumer protection Act.
- Accurate medical records include medical history. Results of Investigations, prescriptions, progress notes, Instructions received from the Consultant In charge of the cases, and other relevant information.
- Record all instructions obtained from the Referring Doctor etc. All notes should be signed, timed and dated. The Notes should be recorded as soon as possible, as we likely to forget important details with passage of time. Do not try to rub out or deface a ink line, and enter the corrected records directly beneath the crossed out entry.
- This ensures that you are merely maintaining accurate records, and not trying to hide something. All the entries in the medical records and also all forms (e.g. Blood Requisition Form, consent form etc.) should be signed.
- You have to write your full name below the signature and wherever required your Medical Council Registration no. should also be mentioned.
- **Medical Certificates** Resident Medical Staff are not authorized to issue medical certificates on behalf of the Hospital. All requests for medical certificates should be directed to the “Director /Medical Suptd. Who are the authorized for issuing medical certificates.

**Medico —Legal cases**
- The hospital has policy of treating all medico legal cases. All cases reporting after accidents / injuries of any nature, suspected poisonings or foul play are to be treated as Medico legal Cases.
- Records of all such cases must be entered into the medico legal book kept in the EMS.
- The Hospital is required to inform the Local Police station within the shortest possible time, about all medico-legal cases treated at the Hospital. Consent of the patient or consultant in-charge for making police report is not required.
- If the