Series: Understanding MSDS | Post 19 of 52
Standard 6 (IMS-1) | Indicator 16 | Category: YELLOW (80% required)
The Handwriting Nobody Could Name
Dr. Haris Javed ran a busy general practice in Okara. Over two years, his receptionist, Naveed, had taken on more and more of the paperwork. He recorded blood pressure and weight on each patient’s card, wrote the complaint, and on busy evenings copied “same medicine” onto the cards of patients returning for repeat treatment.
Dr. Haris signed the cards when he had time. Usually he did not.
The PHC assessor pulled twenty patient cards at random and laid them on the table.
“Doctor, in each of these, who wrote the blood pressure? Who wrote the treatment?”
Some entries were in Dr. Haris’s handwriting, some in Naveed’s, and some nobody could identify. The doctor’s own signature was an initial with no name or stamp. None of Naveed’s entries were signed, and there was no written authorization for Naveed to make entries.
Of the twenty cards, only eleven allowed the assessor to identify, by name and designation, everyone who had written in them.
Indicator 16 was scored as not met.
What Indicator 16 Requires
The indicator reads: Only authorized person/s make entries in the record.
The manual sets out three requirements:
- If a person other than the doctor is delegated to make entries in patient records, that person must be authorized in writing to do so, and their entries must be traceable when required
- The prescription itself is excluded from delegation. Only a qualified doctor registered with the PMDC is allowed to write a prescription
- The name and designation of the doctor writing the prescription, and of the person making entries in other records, must be written in pen or by stamp, and signed
In a single-doctor clinic, the doctor is that person, and should use a stamp under the signature.
The Table of Authorization
The guidelines make the management responsible for designating and authorizing, in writing, the person who maintains the records.
The clinic keeps a list of authorized persons with the documents each may sign, together with their specimen signatures, initials and stamps. The manual’s sample Table of Authorization has columns for serial number, name and position, authorization, initials, signature and stamp, with rows for the doctor, the dispenser and the clerk or assistant.
It is kept on file and updated whenever new signatories are added. For computerised records, the table names the person responsible.
Every entry should also be dated and timed, with the particulars of the person making it.
How It Is Scored
This is a YELLOW indicator, scored on the records checked.
Fully met: the person writing the prescription and the one making other entries can be identified by name and designation in the records checked.
Partially met: they can be identified in 80% of the records checked.
Not met: they can be identified in less than 80% of the records checked.
Dr. Haris’s eleven out of twenty came to 55%.
Why It Matters
A patient record is a legal document. If a dispute arises, the first question will be who wrote each line, and an unsigned entry has no author. A receptionist writing treatment on a card, however well intended, crosses into prescribing, which the manual reserves for a doctor registered with the PMDC.
What Dr. Haris Changed
He drew up a Table of Authorization on a single sheet. Naveed was authorized in writing to record the patient’s particulars, blood pressure and weight, and nothing more. The dispenser was authorized to sign for medicines issued. Both placed their specimen signatures and initials on the sheet, and each received a small name stamp.
Repeat prescriptions were now written only by Dr. Haris.
Dr. Haris ordered a stamp with his name, qualification and PMDC number, and began stamping under his signature on every card, with the date and time.
At reassessment, the assessor pulled twenty cards again. Every entry carried a name, designation and signature. Indicator 16 was fully met.
A Quick Self-Check
- Does anyone other than you write in patient records? Are they authorized in writing?
- Is there a Table of Authorization with specimen signatures, initials and stamps?
- Is every prescription written only by a PMDC registered doctor?
- Does each entry show the name and designation of the writer, by pen or stamp, with a signature?
- Pick ten records today. Can you identify the author of every entry in at least eight?
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