Hematuria - abnormal presence of blood in the urine. It is symptomati of many renal diseases and disorders of the genitourinary system. Microscopic examination of the urine, culture and sensitivity of the urine as well as physical examination of the patient are usually performed.
Hemiplegia - paralysis of one side of the body.
Hemoglobin - a complex protein iron compound in the blood that oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs. Each erythrocyte contains 200 to 300 molecules of hemoglobin, each molecule of hemoglobin contains four groups of heme each group of heme can carry one molecule of oxygen. The normal concentrations of hemoglobin in the blood are 12 to 16 g/dl in women and 13.5 to 18g/dl in men. In an atmosphere of high oxygen concentration, such as in the lungs, hemoglobin binds with oxygen to from oxyhemoglobin. In an atmosphere of low oxygen concentration, such as in the peripheral tissues of the body, oxygen is replaced by carbon dioxide to form carboxyhemoglobin. Hemoglobin releases the carboxyhemoglobin in the lungs for excretion and picks up more oxygen for transport to the cells.
Hemolysis - the breakdown of red blood cells and the release of hemoglobin that occur normally at the end of the life span of a red cell. Hemolysis may occur in antigen antibody reactions, metabolic abnormalities of the red cell that significantly shorten red cell life span, and mechanical trauma such as cardiac prosthesis
Hemoptysis - coughing up of blood from the respiratory tract. Blood streaked sputum oftem is present in minor upper respiratory tract. Blood streaked sptum often is present in minor upper respiratory infections or bronchitis. More profuse bleeding amy indicate Aspergillums infection, lung abscess, turberculosis or bronchogenic carcinoma.
Hemorrhage - a loss of a large amount of blood in a short period, either externally or internally. Hemorrhage may be arterial, venous, or capillary. Symptoms of massive hemorrhage are related to hypovolemic shock: rapid thready pulse; thirst; cold; clammy skin; sighing.
Showing posts with label Ethical and Administrative Issue in Healthcare Sector. Show all posts
Showing posts with label Ethical and Administrative Issue in Healthcare Sector. Show all posts
Sunday, March 7, 2010
Chapter: 6.6 Common Terms
Dialysis - The process of separating colloids and crystalline substances in a solution by the difference in their rate of diffusion through a semi permeable membrane; a medical procedure for the removal of certain elements from the blood or lymph by virtue of the difference in their rates of diffusion through an external semi permeable membrane or, in the case of peritoneal dialysis, through the peritoneum.
Dystonic - referring to impairments of muscle tone, often excessive increase in tone, when the muscle is in action and to hypotomia when it is at rest, often resulting in postural abnormalities.
Epilepsy - a group of neurologic disorders characterized by recurrent episodes of convulsive seizures, sensory disturbances, abnormal behavior, loss of consciousness, or all of these. Common to all types of epilepsy is an uncontrolled electric discharge from the nerve cells of the cerebral cortex. Most epileptic attacks are brief. The frequency of attacks may range from many times a day to intervals of several years.
Evidence based practice - the practice of health care in which the practitioners systematically finds, appraises, and uses the most current and valid research findings as the basis for clinical decisions. The term is sometimes used to denote evidence based medicine specifically, but can also include other specialties, such as evidence based nursing, pharmacy and dentistry.
Flatus - air or gas in the intestine that is passed through the rectum.
Fluid overload - an excessive accumulation of fluid in the body caused by excessive parentral infusion or deficiencies in cardiovascular or renal fluid volume regulation.
Gallbladder - a pear- shaped excretory sac lodged in a fossa on the visceral surface of the right lobe of the liver. It stores and concentrates bile, which it receives from the liver via the hepatic duct. In an adult, it holds about 32mL of bile. During digestion of fats, the gallbladder contracts, ejecting bile through the common bile duct into the duodenum.
Dystonic - referring to impairments of muscle tone, often excessive increase in tone, when the muscle is in action and to hypotomia when it is at rest, often resulting in postural abnormalities.
Epilepsy - a group of neurologic disorders characterized by recurrent episodes of convulsive seizures, sensory disturbances, abnormal behavior, loss of consciousness, or all of these. Common to all types of epilepsy is an uncontrolled electric discharge from the nerve cells of the cerebral cortex. Most epileptic attacks are brief. The frequency of attacks may range from many times a day to intervals of several years.
Evidence based practice - the practice of health care in which the practitioners systematically finds, appraises, and uses the most current and valid research findings as the basis for clinical decisions. The term is sometimes used to denote evidence based medicine specifically, but can also include other specialties, such as evidence based nursing, pharmacy and dentistry.
Flatus - air or gas in the intestine that is passed through the rectum.
Fluid overload - an excessive accumulation of fluid in the body caused by excessive parentral infusion or deficiencies in cardiovascular or renal fluid volume regulation.
Gallbladder - a pear- shaped excretory sac lodged in a fossa on the visceral surface of the right lobe of the liver. It stores and concentrates bile, which it receives from the liver via the hepatic duct. In an adult, it holds about 32mL of bile. During digestion of fats, the gallbladder contracts, ejecting bile through the common bile duct into the duodenum.
Chapter: 6.5 Diabetes Mellitus
Diabetes Mellitus - a complex disorder of carbohydrate, fat and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion by the beta cells of the pancreas or resistance to insulin. The various forms of diabetes have been organized into categories developed by the Expert Committee on the Diagnosis and Classification of diabetes mellitus of the American Diabetes Association. Type 1 diabetes mellitus in this classification scheme includes patients with diabetes caused by an autoimmune process, dependent on insulin to prevent ketosis. This group was previously called type I, insulin dependent diabetes mellitus (IDDM), juvenile onset diabetes, adult onset diabetes, ketosis prone diabetes, patients with type 2 diabetes mellitus are those previously designated as having type II non insulindependent diabetes mellitus (NDDM), maturity onset diabetes, adult onset diabetes, ketosis resistant diabetes, or stable diabetes. The onset of type 1 diabetes mellitus is sudden in children. Type 2 diabetes often begins insidiously. Those with gestational diabetes mellitus are women in whom glucose intolerance develops during pregnancy. Other types of diabetes are associated with a pancreatic disease, hormonal changes, adverse effects of drugs, or genetic or other anomalies. A fourth subclass, the impaired glucose tolerance group, also called pre diabetes includes persons whose blood glucose levels are abnormal although not sufficiently above the normal range to be diagnosed as having diabetes. Approximately 95% of the 18 million diabetes patients in the United States are classified as type 2, and more that 70% of those patients are obese. Contributing factors to the development of diabetes are heredity, obesity, sedentary life style, high fat low- fiber diets, hypertension and aging. The goal of treatment is to maintain insulin glucose homeostasis. Type 1 diabetes is controlled by insulin, meal planning and exercise. Tight control of blood glucose level [i.e. frequent monitoring and maintenance at as close to normal as possible to the level of non diabetics] significantly reduces complications such as eye disease, kidney disease and nerve damage. Type 2 diabetes is controlled by meal planning, exercise, one or more oral agents, and insulin, stress of any kind may require medication adjustment in both type 1 and type 2 diabetes.
Chapter: 6.4 Common Terms
Catharsis - A cleaning or purging; the therapeutic release of pent up feelings and emotions by open discussion of ideas and thoughts; the process of drawing repressed ideas and feelings into the consciousness by the technique of free association, often in conjunction with hypnosis and use of-hypnotic drugs.
Catheter - A hollow flexible tube that can be inserted into a vessel or cavity of the body to withdraw or to instill fluids, directly monitor various types of information and visualize a vessel or cavity.
Cauterize - To burn tissues by thermal heat including steam, hot metal or solar radiation; electricity; or another agent, such as laser or dry ice, usually with the objective of destroying damaged or diseased tissues, preventing infections, or coagulating blood vessels.
Chronic Obstructive Pulmonary Disease - a progressive and irreversible condition characterized by diminished inspiratory and expiratory capacity of the lungs. The condition is aggravated by cigarette smoking and air pollution. COPDs include asthma, chronic bronchiectasis, chronic bronchitis, and emphysema.
Congenital - present at birth, as a congenital anomaly or defect.
Conjunctivitis - inflammation of the conjunctive caused by bacterial or viral infection, allergy or environmental factors. Red eyes, thick discharge, sticky eyelids in the morning, and inflammation without pain are characteristic.
Cyst - a closed sac in or under the skin lined with epithelium and containing fluid or semisolid material. It may or may not be infected
Defibrillator - a device that delivers an electrical shock at a preset voltage to the myoeardium. It is used from restoring the normal cardiac rhythm and rate when the heart has stopped beating or is fibrillating
Diabetes insipidus - a metabolic disorder caused by injury of the neurohypophyseal system. It is characterized by copious excretion of urine and excessive thirst, caused by deficient production of secretion of the antidiuretic hormone (ADH) or inability of the kidney tubules to respond to ADH. Rarely the symptoms are self induced by an excessive water intake. The condition may be acquired, familial, idiopathic, neurogenic, nephrogenic or psychogenic.
Catheter - A hollow flexible tube that can be inserted into a vessel or cavity of the body to withdraw or to instill fluids, directly monitor various types of information and visualize a vessel or cavity.
Cauterize - To burn tissues by thermal heat including steam, hot metal or solar radiation; electricity; or another agent, such as laser or dry ice, usually with the objective of destroying damaged or diseased tissues, preventing infections, or coagulating blood vessels.
Chronic Obstructive Pulmonary Disease - a progressive and irreversible condition characterized by diminished inspiratory and expiratory capacity of the lungs. The condition is aggravated by cigarette smoking and air pollution. COPDs include asthma, chronic bronchiectasis, chronic bronchitis, and emphysema.
Congenital - present at birth, as a congenital anomaly or defect.
Conjunctivitis - inflammation of the conjunctive caused by bacterial or viral infection, allergy or environmental factors. Red eyes, thick discharge, sticky eyelids in the morning, and inflammation without pain are characteristic.
Cyst - a closed sac in or under the skin lined with epithelium and containing fluid or semisolid material. It may or may not be infected
Defibrillator - a device that delivers an electrical shock at a preset voltage to the myoeardium. It is used from restoring the normal cardiac rhythm and rate when the heart has stopped beating or is fibrillating
Diabetes insipidus - a metabolic disorder caused by injury of the neurohypophyseal system. It is characterized by copious excretion of urine and excessive thirst, caused by deficient production of secretion of the antidiuretic hormone (ADH) or inability of the kidney tubules to respond to ADH. Rarely the symptoms are self induced by an excessive water intake. The condition may be acquired, familial, idiopathic, neurogenic, nephrogenic or psychogenic.
Chapter: 6.3 Common Terms
Blue baby - an infant born with cyanosis caused by a congenital heart lesion, most commonly tetralogy of Fallot. Congenital cyanotic heart lesions are diagnosed by cardiac catheterization, angiography, or echocardiography and are corrected surgically, preferably in early childhood.
Bone marrow - transplantation the IV infusion of bone marrow. The marrow may be autologous [from a previously harvested and stored self donation] or aoogeneic[from a living donor]. It is used to treat malignancies, such as leukemia, lymphoma, myeloma, and selected solid tumors; and nonmalignant conditions, such as aplastic anemia, immunologic deficiencies, and inborn errors of metabolism.
Brachytheraphy - the placement of radioactive sources in contact with or implanted into the tumor tissues to be treated for a specific period.
Bradycardia - a condition in which the heart rate is less than 60 beats/ min. Brady cardia takes the form of sinus bradycardia, sinus arrhythmia, and second- or third degree artrioventricular block.
Brain death - an irreversible form of unconsciousness characterized by a complete loss of brain function while the heart continues to beat. The legal definition of this condition varies from state to state. The usual clinical criteria for brain death include the absence of reflex activity, movements, and spontaneous respiration requiring mechanical ventilation or life support to continue any cardiac function. The pupils are dilated and fixed. Because hypothermia, anaesthesia, poisoning, or drug intoxication may cause deep physiologic depression that resembles brain death these parameters must be within normal limits prior to testing. Diagnosis of brain death may require evaluating and demonstrating that electrical activity of the brain is absent on two electroencephalograms performed 12 to 24 hours apart.
Bronchodilator - a substance, especially a drug, that relaxes contractions of the smooth muscle of the bronchioles to improve ventilation to the lung's, pharmacologic bronchodilators are prescribed to improve aeration in asthma, bronchiectasis, bronchitis, and emphysema. Commonly used bronchodilators include albuterol, terbutaline, and various derivatives and combinations of these drugs.
Cadaver graft - the transfer of tissue from the body of a dead individual to repair a defect in a living person.
Cardiac Catheterization - a diagnostic procedure in which a catheter is introduced through an incision into a large vein, usually of an arm or a leg, and threaded through the circulatory system to the heart. The course of the catheter is followed with fluoroscopy, and radiographs may be taken. An electrocardiogram is monitored on an oscilloscope. As the catheter tip passes through the chambers and vessels of the heart, blood pressure is monitored, and blood samples are taken to study the oxygen content. Many conditions may be accurately identified and assessed, including congenital heart disease. Tricuspid stenosis and valvular incompetence.
Bone marrow - transplantation the IV infusion of bone marrow. The marrow may be autologous [from a previously harvested and stored self donation] or aoogeneic[from a living donor]. It is used to treat malignancies, such as leukemia, lymphoma, myeloma, and selected solid tumors; and nonmalignant conditions, such as aplastic anemia, immunologic deficiencies, and inborn errors of metabolism.
Brachytheraphy - the placement of radioactive sources in contact with or implanted into the tumor tissues to be treated for a specific period.
Bradycardia - a condition in which the heart rate is less than 60 beats/ min. Brady cardia takes the form of sinus bradycardia, sinus arrhythmia, and second- or third degree artrioventricular block.
Brain death - an irreversible form of unconsciousness characterized by a complete loss of brain function while the heart continues to beat. The legal definition of this condition varies from state to state. The usual clinical criteria for brain death include the absence of reflex activity, movements, and spontaneous respiration requiring mechanical ventilation or life support to continue any cardiac function. The pupils are dilated and fixed. Because hypothermia, anaesthesia, poisoning, or drug intoxication may cause deep physiologic depression that resembles brain death these parameters must be within normal limits prior to testing. Diagnosis of brain death may require evaluating and demonstrating that electrical activity of the brain is absent on two electroencephalograms performed 12 to 24 hours apart.
Bronchodilator - a substance, especially a drug, that relaxes contractions of the smooth muscle of the bronchioles to improve ventilation to the lung's, pharmacologic bronchodilators are prescribed to improve aeration in asthma, bronchiectasis, bronchitis, and emphysema. Commonly used bronchodilators include albuterol, terbutaline, and various derivatives and combinations of these drugs.
Cadaver graft - the transfer of tissue from the body of a dead individual to repair a defect in a living person.
Cardiac Catheterization - a diagnostic procedure in which a catheter is introduced through an incision into a large vein, usually of an arm or a leg, and threaded through the circulatory system to the heart. The course of the catheter is followed with fluoroscopy, and radiographs may be taken. An electrocardiogram is monitored on an oscilloscope. As the catheter tip passes through the chambers and vessels of the heart, blood pressure is monitored, and blood samples are taken to study the oxygen content. Many conditions may be accurately identified and assessed, including congenital heart disease. Tricuspid stenosis and valvular incompetence.
Chapter: 6.2 Common Terms
Antifungal - Pertaining to a substance that kills fungi or inhibits their growth or reproduction; an antifungal, antibiotic drug. Amphotericin B and ketoconazole, both effective against a broad spectrum of fungi, probably act by binding to sterols in the fungal cell membrane and changing the membrane's permeability. Griseofulvin, another broad spectrum antifungal agent, binds to the host's new keratin and renders it resistant to further fungal invasion. Miconazole inhibits the growth of common dermatophytes, including yeastlike Candid albicans; nystain is effective against yeast and yeast like fungi.
Apendicitis - inflammation of the vermiform appendix, usually acute, that if undiagnosed leads rapidly to perforation and peritonitis. The inflammation is caused by an obstruction such as a hard mass of feces or a foreign body in the lumen of the appendix, fibrous disease of the bowel wall, an adhesion, or a parasitic infestation. The most common symptom is constant pain in the right lower quadrant of the abdomen around McBurney's point, which the patient describes as having begun as intermittent pain in midabdomen. Extreme tenderness occurs over the right rectus muscle. Appendicitis is also characterized by vomiting, a low grade fever of 990 to 1020 F. an elevated white blood count, rebound tenderness, a rigid abdomen and decreased or absent bowel sounds. Treatment is appendectomy within 24 to 48 hours of the first symptoms because delay usually results in rupture and peritonitis as fecal matter is released into the peritoneal cavity.
Autopsy - a postmortem examination performed to confirm or determine the cause of death. autopsic, autopsical, the study of disease by the examination of the body after death by a pathologist.
Bacille, Calmette-Guerin - an attenuated strain of mycobacterium bovis attenuated strain of mycobacterium bovis that is given as a live bacterial vaccine to prevent the development of TB. It is most often administered intradermally, with a multiple puncture disk. When administered to infants in high prevalence areas, there is some evidence that it prevents the more serious forms of tuberculosis. It may have some efficacy against leprosy. BCG is also instilled into the bladder as a treatment for bladder cancer to stimulate the immune response in people who have certain kinds of malignancy.
Battered Woman Syndrome - repeated episodes of physical assault on a woman by the person with whom she liver or with whom she has a relationship, often resulting in serous physical and psychological damage to the woman. Such violence tends to follow a predictable pattern, starting with verbal abuse, progressing to acute, violent activity, and followed by apologies, remorse, and promises of change. Over time, the violent episodes escalate in frequency and severity.
Blood Pressure - the pressure exerted by the circulating volume of blood on the walls of the arteries and veins and on the chambers of the heart. Blood pressure is regulated by the homeostatic mechanisms of the body by the volume of the blood, the lumen of the arteries and arterioles, and the force of cardiac contraction. In the aorta and large arteries of a healthy young adult, blood pressure is approximately 120 mm Hg during systole and 70 mm Hg during diastole.
Blood Urea Nitrogen - a measure of he amount of urea in the blood. The BUN, determined by a blood test, is directly related to the metabolic function of the liver and the excretory function of the kidney. Normal findings (in mg/ dl) are 1.0-20 for adults, 5218 for children and infants. 312 for newborns and 21-40 for cord blood. In the elderly the BUN may be slightly higher than the normal adult range. A critical value of 100 mg/ dl indicates serious impairment of renal function.
Apendicitis - inflammation of the vermiform appendix, usually acute, that if undiagnosed leads rapidly to perforation and peritonitis. The inflammation is caused by an obstruction such as a hard mass of feces or a foreign body in the lumen of the appendix, fibrous disease of the bowel wall, an adhesion, or a parasitic infestation. The most common symptom is constant pain in the right lower quadrant of the abdomen around McBurney's point, which the patient describes as having begun as intermittent pain in midabdomen. Extreme tenderness occurs over the right rectus muscle. Appendicitis is also characterized by vomiting, a low grade fever of 990 to 1020 F. an elevated white blood count, rebound tenderness, a rigid abdomen and decreased or absent bowel sounds. Treatment is appendectomy within 24 to 48 hours of the first symptoms because delay usually results in rupture and peritonitis as fecal matter is released into the peritoneal cavity.
Autopsy - a postmortem examination performed to confirm or determine the cause of death. autopsic, autopsical, the study of disease by the examination of the body after death by a pathologist.
Bacille, Calmette-Guerin - an attenuated strain of mycobacterium bovis attenuated strain of mycobacterium bovis that is given as a live bacterial vaccine to prevent the development of TB. It is most often administered intradermally, with a multiple puncture disk. When administered to infants in high prevalence areas, there is some evidence that it prevents the more serious forms of tuberculosis. It may have some efficacy against leprosy. BCG is also instilled into the bladder as a treatment for bladder cancer to stimulate the immune response in people who have certain kinds of malignancy.
Battered Woman Syndrome - repeated episodes of physical assault on a woman by the person with whom she liver or with whom she has a relationship, often resulting in serous physical and psychological damage to the woman. Such violence tends to follow a predictable pattern, starting with verbal abuse, progressing to acute, violent activity, and followed by apologies, remorse, and promises of change. Over time, the violent episodes escalate in frequency and severity.
Blood Pressure - the pressure exerted by the circulating volume of blood on the walls of the arteries and veins and on the chambers of the heart. Blood pressure is regulated by the homeostatic mechanisms of the body by the volume of the blood, the lumen of the arteries and arterioles, and the force of cardiac contraction. In the aorta and large arteries of a healthy young adult, blood pressure is approximately 120 mm Hg during systole and 70 mm Hg during diastole.
Blood Urea Nitrogen - a measure of he amount of urea in the blood. The BUN, determined by a blood test, is directly related to the metabolic function of the liver and the excretory function of the kidney. Normal findings (in mg/ dl) are 1.0-20 for adults, 5218 for children and infants. 312 for newborns and 21-40 for cord blood. In the elderly the BUN may be slightly higher than the normal adult range. A critical value of 100 mg/ dl indicates serious impairment of renal function.
Chapter: 6.1 Common Terms
Acetaminophen an analgesic and antipyretic drug used in many non prescription pain relievers. It has no antiinflammatory properties. It may be used in combination with other products which do not contain additional acetaminophen. It is often recommended for treatment of mild to moderate pain and fever.
Allergy - a hypersensitive reaction to common, often intrinsically harmless substances most of which are environmental. Severe allergic reactions, such as anaphylaxis and angioneurotic edema of the glottis, can cause systematic shock and death and commonly require immediate therapy with subcutaneous epinephrine or IV steroids.
Antibiotic - Pertaining to the ability to destroy or interfere with the development of a living organism; an antimicrobial agent, derived from cultures of microorganisms or produced semisynthetically, used to treat infections. Classes of antibiotics include penicillins, aminoglycosides, macrollide antibiotics, polypeptide antibiotics, tetracyclines, and cephalosporins.
Anticogulant - Pertaining to a substance that prevents or delays coagulation of the blood; an anticoagulant drug. Heparin is a potent anticoagulant that interferes with the formation of thromboplastin, with the conversion of prothrombin to thrombin and with the formation of fibrin from fibrinogen. Phenindion derivatives administered orally or by injection are vitamin K antagonists that prevent coagulation by inhibiting the formation of vitamin K-dependent clotting factors.
Antiemetic - Pertaining to a substance or procedure that prevents or alleviates nausea and vomiting; an antiemetic drug or agent. Chlorpromazine and other phenothiazines are sometimes effective antiemetic agents. In motion sickness, scopolamine and antihistamines provide relief. SHT3- receptor antagonists such as dolasteron and the corticosteroid dexamethasone may relieve chemotherapy induced nausea. Cannabis derivatives such as dronabinol may also-alleviate the nausea induced by certain antineoplastic drugs in cancer patients.
Allergy - a hypersensitive reaction to common, often intrinsically harmless substances most of which are environmental. Severe allergic reactions, such as anaphylaxis and angioneurotic edema of the glottis, can cause systematic shock and death and commonly require immediate therapy with subcutaneous epinephrine or IV steroids.
Antibiotic - Pertaining to the ability to destroy or interfere with the development of a living organism; an antimicrobial agent, derived from cultures of microorganisms or produced semisynthetically, used to treat infections. Classes of antibiotics include penicillins, aminoglycosides, macrollide antibiotics, polypeptide antibiotics, tetracyclines, and cephalosporins.
Anticogulant - Pertaining to a substance that prevents or delays coagulation of the blood; an anticoagulant drug. Heparin is a potent anticoagulant that interferes with the formation of thromboplastin, with the conversion of prothrombin to thrombin and with the formation of fibrin from fibrinogen. Phenindion derivatives administered orally or by injection are vitamin K antagonists that prevent coagulation by inhibiting the formation of vitamin K-dependent clotting factors.
Antiemetic - Pertaining to a substance or procedure that prevents or alleviates nausea and vomiting; an antiemetic drug or agent. Chlorpromazine and other phenothiazines are sometimes effective antiemetic agents. In motion sickness, scopolamine and antihistamines provide relief. SHT3- receptor antagonists such as dolasteron and the corticosteroid dexamethasone may relieve chemotherapy induced nausea. Cannabis derivatives such as dronabinol may also-alleviate the nausea induced by certain antineoplastic drugs in cancer patients.
Chapter: 6 Basic Medical Terminologies
Basic Medical Terminologies
Objectives
After undergoing this module, you will be able to
• Describe how medical terms are constituted
• Explain the meaning of commonly used Medical Terms
Introduction
Before we go to commonly used medical terms, we will see how medical terms are constituted. There are three basic parts to a medical term: a word root (usually the middle of the word and its central meanings, a prefix (comes at the beginning and usually identifies some subdivision or part of the central meaning), and a suffix (comes at the end and modifies the central meaning as to what or who is interacting with it or what is happening to it). An example may make things clear. E.g. the medical term Myocarditis can be divided into three parts; Myo (prefix) which means muscle, card (root) which means heart and ills (suffix) which means inflammation.
If you change the prefix, or the suffix we can see the change of meaning.
Myocarditis = muscle layer of heart inflamed
Pericarditis = outer layer of heart inflamed
Endocarditis = inner layer of heart inflamed
Cardiologist = a physician specializing in the damage to heart
Cardiomyopathy = damage to heart muscle layer
Cardiomegaly = enlargement of the heart
Objectives
After undergoing this module, you will be able to
• Describe how medical terms are constituted
• Explain the meaning of commonly used Medical Terms
Introduction
Before we go to commonly used medical terms, we will see how medical terms are constituted. There are three basic parts to a medical term: a word root (usually the middle of the word and its central meanings, a prefix (comes at the beginning and usually identifies some subdivision or part of the central meaning), and a suffix (comes at the end and modifies the central meaning as to what or who is interacting with it or what is happening to it). An example may make things clear. E.g. the medical term Myocarditis can be divided into three parts; Myo (prefix) which means muscle, card (root) which means heart and ills (suffix) which means inflammation.
If you change the prefix, or the suffix we can see the change of meaning.
Myocarditis = muscle layer of heart inflamed
Pericarditis = outer layer of heart inflamed
Endocarditis = inner layer of heart inflamed
Cardiologist = a physician specializing in the damage to heart
Cardiomyopathy = damage to heart muscle layer
Cardiomegaly = enlargement of the heart
Chapter: 5.2.5 Salient Features
Acquittal: Acquittal is order of court declaring an accused not guilty of the offence allege and charged against him.
Defamation: Defamation is the publication of a statement, expressly stated or implied to factual, that may harm the reputation of an individual.
Omission: Omission is failure to do something which any reasonable man with ordinary prudence would have done. .
Conveyance: This is the procedure by which any movable or immovable property is transferred from person to another. For e.g., Sale, Lease, Mortgage.
Intention: Intention is the first stage of criminal liability. It signifies that "unlawful object” to be attained by an accused while committing a crime. For e.g., while committing theft, the intention of accused is to deprive a person of a property, without his consent, which is in possession of other person.
Motive: In legal terms this is defined as "intention behind intention". For e.g., a person intends to kill somebody for revenge. "Revenge" is the motive.
Trespass: Trespass can be defined as an act of entering into somebody else's land or property without permission of the owner or person in possession. Trespass can be civil as well as criminal.
Nuisance: Nuisance is a tort which the right of enjoyment is being infringed. Nuisance is divided into public nuisance and private nuisance.
Ratification: Ratification is the act of giving sanction to an act, which has been done prior to She said sanction.
Will: Will is a document expressing the desires of the testator with regard to the disposition of property after his death.
Defamation: Defamation is the publication of a statement, expressly stated or implied to factual, that may harm the reputation of an individual.
Omission: Omission is failure to do something which any reasonable man with ordinary prudence would have done. .
Conveyance: This is the procedure by which any movable or immovable property is transferred from person to another. For e.g., Sale, Lease, Mortgage.
Intention: Intention is the first stage of criminal liability. It signifies that "unlawful object” to be attained by an accused while committing a crime. For e.g., while committing theft, the intention of accused is to deprive a person of a property, without his consent, which is in possession of other person.
Motive: In legal terms this is defined as "intention behind intention". For e.g., a person intends to kill somebody for revenge. "Revenge" is the motive.
Trespass: Trespass can be defined as an act of entering into somebody else's land or property without permission of the owner or person in possession. Trespass can be civil as well as criminal.
Nuisance: Nuisance is a tort which the right of enjoyment is being infringed. Nuisance is divided into public nuisance and private nuisance.
Ratification: Ratification is the act of giving sanction to an act, which has been done prior to She said sanction.
Will: Will is a document expressing the desires of the testator with regard to the disposition of property after his death.
Chapter: 5.2.4 Salient Features
Fine: Fine is money paid as a pecuniary sanction for the commission of offence.
Plaint: Plaint is a legal document, which contains in detail the subject matter of a particular civil proceeding. It sets out the basic facts that would entitle the plaintiff to a remedy.
Complaint: As plaint in civil, Complaint is used in sense of criminal proceedings in India.
Complainant: As Plaintiff, Complainant is the party who initiates a legal proceeding. This term is generally referred in a criminal proceeding.
Warrant: Warrant is order of a Court enforcing appearance of a party of the proceeding / witness, if such party / witness fails to appear on the scheduled date of appearance on service of summons.
Confiscation: Confiscation, is obtaining custody of material and goods by a government or other public authority.
Search Warrant: Search warrant is an order by the Magistrate which authorizes the police to conduct a search of a person or location to obtain evidence in respect to a criminal proceeding.
Simmons: Summons is again order of a Court, directing party to the proceeding to appear before the Court on the date as mentioned in the summons.
Injunction: Injunction is an, whereby a party is required to do, or to refrain from doing, ~ pertain acts. Injunction may be temporary or permanent.
Affidavit: An affidavit is a formal statement of fact, signed by the affiant on oath.
Conviction: Conviction is the order passed the court declaring the accused to be guilty of a crime.
Plaint: Plaint is a legal document, which contains in detail the subject matter of a particular civil proceeding. It sets out the basic facts that would entitle the plaintiff to a remedy.
Complaint: As plaint in civil, Complaint is used in sense of criminal proceedings in India.
Complainant: As Plaintiff, Complainant is the party who initiates a legal proceeding. This term is generally referred in a criminal proceeding.
Warrant: Warrant is order of a Court enforcing appearance of a party of the proceeding / witness, if such party / witness fails to appear on the scheduled date of appearance on service of summons.
Confiscation: Confiscation, is obtaining custody of material and goods by a government or other public authority.
Search Warrant: Search warrant is an order by the Magistrate which authorizes the police to conduct a search of a person or location to obtain evidence in respect to a criminal proceeding.
Simmons: Summons is again order of a Court, directing party to the proceeding to appear before the Court on the date as mentioned in the summons.
Injunction: Injunction is an, whereby a party is required to do, or to refrain from doing, ~ pertain acts. Injunction may be temporary or permanent.
Affidavit: An affidavit is a formal statement of fact, signed by the affiant on oath.
Conviction: Conviction is the order passed the court declaring the accused to be guilty of a crime.
Chapter: 5.2.3 Salient Features
Power of Attorney: A power of attorney is a kind of agency. It is instrument of authorization to act on someone else's behalf in the matter, which are mentioned in the Power of Attorney. The person authorizing the other to act is the principal or grantor (of the power), and the one authorized to act is the agent or attorney or grantee.
Deed: Deed is a legal document used to grant / convey a right. For e.g., Sale Deed, Lease Deed.
F.I.R.: FIR, is shortened version of First Information Report. It is a report of formation that reaches the police authorities concerned first in point of time and that is why it is called the First Information Report. FIR can be made orally Cur in writing by the victim of a cognizable offence or by someone on his/her half or by any other person.
Witness: Witness is someone who has knowledge about the matter contained in any legal proceeding, whether civil or criminal. A witness who has seen the event firsthand is known as an eye-witness. Witnesses are often called before a court of law to depose about the subject matter of the proceeding.
Hostile Witness: Hostile witness is a witness in a criminal trial who deviates from his original statement made to Police. For e.g., A made a statement to the Police stating that he has seen B stabbing C. However during the Court trials, he deviates from the statement made to the police and informs the Court that he was not present during the occurrence of crime. A is declared as Hostile Witness.
Evidence: Evidence, refers to anything that is used to prove or disprove any fact in issue. For e.g., An Identity Card can prove that A is student of a particular institution. Therefore Identity Card is evidence.
Negligence: Negligence is a type of tort. It means that an individual through his act or omission has breached certain duty towards other members of society which has resulted in damages to the said individual. Negligent acts / omission gives the aggrieved party right to be compensated for the harm to their body, property, mental well-being, financial status, or relationships.
Deed: Deed is a legal document used to grant / convey a right. For e.g., Sale Deed, Lease Deed.
F.I.R.: FIR, is shortened version of First Information Report. It is a report of formation that reaches the police authorities concerned first in point of time and that is why it is called the First Information Report. FIR can be made orally Cur in writing by the victim of a cognizable offence or by someone on his/her half or by any other person.
Witness: Witness is someone who has knowledge about the matter contained in any legal proceeding, whether civil or criminal. A witness who has seen the event firsthand is known as an eye-witness. Witnesses are often called before a court of law to depose about the subject matter of the proceeding.
Hostile Witness: Hostile witness is a witness in a criminal trial who deviates from his original statement made to Police. For e.g., A made a statement to the Police stating that he has seen B stabbing C. However during the Court trials, he deviates from the statement made to the police and informs the Court that he was not present during the occurrence of crime. A is declared as Hostile Witness.
Evidence: Evidence, refers to anything that is used to prove or disprove any fact in issue. For e.g., An Identity Card can prove that A is student of a particular institution. Therefore Identity Card is evidence.
Negligence: Negligence is a type of tort. It means that an individual through his act or omission has breached certain duty towards other members of society which has resulted in damages to the said individual. Negligent acts / omission gives the aggrieved party right to be compensated for the harm to their body, property, mental well-being, financial status, or relationships.
Chapter: 5.2.2 Salient Features
Suit: It is civil action brought before a court, to establish violation of private right and recover damages or any other relief.
Damages: Damages refer to the sum of money decreed to the plaintiff in the judgment passed by the Court.
Compensation: This also refers to sum of money recoverable by the Plaintiff from the Defendant on grounds of breach of duty by the Defendant.
Offence: An offence is a violation of the penal law. In India, major penal law is know as Indian Penal Code, 1860.
Breach: Breach is violation of the terms and conditions of the Agreement. In torts, it is violation of duty of an individual towards other.
Right: Right is basically some king of entitlement or privileges which an individual enjoys being a member of particular society. For e.g., Right to property, Right to express.
Fundamental Rights: Fundamental rights usually encompass those rights which are considered as basic rights required for dignified existence. In India, fundamental rights are enshrined in the Part III of the Constitution. Some of important fundamental rights are: Right to life, Right to equality, Right to equal opportunity in case of employment.
Statutory Rights: Statutory right is a right conferred upon an individual by a statute [Law]. For example, Code of Civil Procedure provides for remedy of Appeal to a party aggrieved by the judgment of the lower Court and therefore right to appeal would be considered statutory.
Contract: Contract is a legally enforceable exchange of promises or agreement between parties. Contract law is based on the Latin phrase 'pacta sunt servanda', which means that the, "agreements must be kept".
Agent: Agent is a person authorized to act on behalf of another persona person.
Damages: Damages refer to the sum of money decreed to the plaintiff in the judgment passed by the Court.
Compensation: This also refers to sum of money recoverable by the Plaintiff from the Defendant on grounds of breach of duty by the Defendant.
Offence: An offence is a violation of the penal law. In India, major penal law is know as Indian Penal Code, 1860.
Breach: Breach is violation of the terms and conditions of the Agreement. In torts, it is violation of duty of an individual towards other.
Right: Right is basically some king of entitlement or privileges which an individual enjoys being a member of particular society. For e.g., Right to property, Right to express.
Fundamental Rights: Fundamental rights usually encompass those rights which are considered as basic rights required for dignified existence. In India, fundamental rights are enshrined in the Part III of the Constitution. Some of important fundamental rights are: Right to life, Right to equality, Right to equal opportunity in case of employment.
Statutory Rights: Statutory right is a right conferred upon an individual by a statute [Law]. For example, Code of Civil Procedure provides for remedy of Appeal to a party aggrieved by the judgment of the lower Court and therefore right to appeal would be considered statutory.
Contract: Contract is a legally enforceable exchange of promises or agreement between parties. Contract law is based on the Latin phrase 'pacta sunt servanda', which means that the, "agreements must be kept".
Agent: Agent is a person authorized to act on behalf of another persona person.
Chapter: 5.2.1 Salient Features
Salient Features
Medical practice in the twenty-first century is not the same as it was in the twentieth century. Newer diseases and problems are now encountered and to tackle them, newer drugs and newer surgical techniques have also been formulated. With the advent of technology, both diagnostic and therapeutic, immense responsibility is laid on the shoulders of the medical man to see that the advances made are used only to the benefit of mankind and not otherwise.
Appeal: An appeal is a process for making a formal challenge to judgment passed by Aloe Lower Court. Appeal is always made to a higher judicial authority.
Cause of action: Cause of action is a recognized kind of legal claim that a plaintiff pleads or alleges in a complaint to institute the legal proceeding. For e.g., in a suit for trespass, the cause of action can be illegal entry of a third party. Similarly, failure to pay the money can be a cause of action for money suit.
Accused: A person charged with a criminal offence. For e.g., in a criminal proceeding of first instance, if the case title is State of Maharashtra v/s B. it is to be understood ; that B is Accused.
Bail: Bail is some form of property deposited with the court adjudicating the offence, as a security to release an accused from jail, on the understanding that the suspect will return for trial or forfeit the bail.
Arrest: Fin arrest is the action of the police, to take a person into custody. In India, arrest can be made with or without warrant. In all cognizable cases like murder, rape arrest can be made without warrant. Whereas in non cognizable cases, arrest can be made only with the permission of the Magistrate. .
Cognizance: Of the adjudicating Court finds that the complainant has a prima facie case, the f Court initiates the legal proceeding and this is called as taking cognizance. On I plying cognizance, the Court issues summons / notice to the Accused to appear I before the Court and answer the charges.
Medical practice in the twenty-first century is not the same as it was in the twentieth century. Newer diseases and problems are now encountered and to tackle them, newer drugs and newer surgical techniques have also been formulated. With the advent of technology, both diagnostic and therapeutic, immense responsibility is laid on the shoulders of the medical man to see that the advances made are used only to the benefit of mankind and not otherwise.
Appeal: An appeal is a process for making a formal challenge to judgment passed by Aloe Lower Court. Appeal is always made to a higher judicial authority.
Cause of action: Cause of action is a recognized kind of legal claim that a plaintiff pleads or alleges in a complaint to institute the legal proceeding. For e.g., in a suit for trespass, the cause of action can be illegal entry of a third party. Similarly, failure to pay the money can be a cause of action for money suit.
Accused: A person charged with a criminal offence. For e.g., in a criminal proceeding of first instance, if the case title is State of Maharashtra v/s B. it is to be understood ; that B is Accused.
Bail: Bail is some form of property deposited with the court adjudicating the offence, as a security to release an accused from jail, on the understanding that the suspect will return for trial or forfeit the bail.
Arrest: Fin arrest is the action of the police, to take a person into custody. In India, arrest can be made with or without warrant. In all cognizable cases like murder, rape arrest can be made without warrant. Whereas in non cognizable cases, arrest can be made only with the permission of the Magistrate. .
Cognizance: Of the adjudicating Court finds that the complainant has a prima facie case, the f Court initiates the legal proceeding and this is called as taking cognizance. On I plying cognizance, the Court issues summons / notice to the Accused to appear I before the Court and answer the charges.
Chapter: 5.1 Medical Ethics Introduction
Introduction
The Medical Ethics has been an integral part of the medical education from the ancient times. Great care was taken to select the right type of students to study the art and science of medicine under the overall supervision of the learned teachers. Much importance was attached to the moral and social values since the physician had to deal with family members in their home environment. The emphasis was on simplicity of life and purity of thoughts and conduct. Respect for teachers was inculcated from the beginning. As time went on, things started deteriorating. The onus of ensuring a good standard of behavior, since then, is entrusted with professional bodies.
On completion of the medical education, an oath is administered which emphasis on the following points:
1. The physician must be neat and clean in appearance. Her dress should be simple.
2. The physician must be pure and good in her behavior. Her speech should be mild and pleasing.
3. The physician must not practice deceit. He should have brotherly feeling towards all creatures.
4. The physician must possess sufficient assistant and equipments required for her practice.
5. The physician should never visit the patients' house uninvited. He will not become friendly with the women of the household and stay with them when they are alone.
6. The physician will maintain good relations with other physicians.
Hippocrates, the Greek Physician who lived 25 centuries ago, also laid great emphasis on the ethical conduct of the physicians and formulated the famous Hippocratic Oath which was based on the principle, "where there is love of humanity, there will be love of medical professions". The Hippocratic Oath is reproduced in the Appendix 1. The basic principles are still valid.
The World Medical Association has simplified the Hippocratic Oath within the modern concept and is now termed as the Declaration of Geneva upon which the International Code of Medical Ethics is based. The declaration is also adopted by the Medical Council of India. This is reproduced in Appendix 2.
The Medical Ethics has been an integral part of the medical education from the ancient times. Great care was taken to select the right type of students to study the art and science of medicine under the overall supervision of the learned teachers. Much importance was attached to the moral and social values since the physician had to deal with family members in their home environment. The emphasis was on simplicity of life and purity of thoughts and conduct. Respect for teachers was inculcated from the beginning. As time went on, things started deteriorating. The onus of ensuring a good standard of behavior, since then, is entrusted with professional bodies.
On completion of the medical education, an oath is administered which emphasis on the following points:
1. The physician must be neat and clean in appearance. Her dress should be simple.
2. The physician must be pure and good in her behavior. Her speech should be mild and pleasing.
3. The physician must not practice deceit. He should have brotherly feeling towards all creatures.
4. The physician must possess sufficient assistant and equipments required for her practice.
5. The physician should never visit the patients' house uninvited. He will not become friendly with the women of the household and stay with them when they are alone.
6. The physician will maintain good relations with other physicians.
Hippocrates, the Greek Physician who lived 25 centuries ago, also laid great emphasis on the ethical conduct of the physicians and formulated the famous Hippocratic Oath which was based on the principle, "where there is love of humanity, there will be love of medical professions". The Hippocratic Oath is reproduced in the Appendix 1. The basic principles are still valid.
The World Medical Association has simplified the Hippocratic Oath within the modern concept and is now termed as the Declaration of Geneva upon which the International Code of Medical Ethics is based. The declaration is also adopted by the Medical Council of India. This is reproduced in Appendix 2.
Chapter: 5 Medical Ethics
Medical Ethics
Objectives
After going through this chapter, you will be able to:
• Know the historical backgrounds of Medical Ethics and their evolution to the present day concept.
• Understand the salient features which constitute as Ethical Conduct on the part of the Registered Medical, Practitioner
Objectives
After going through this chapter, you will be able to:
• Know the historical backgrounds of Medical Ethics and their evolution to the present day concept.
• Understand the salient features which constitute as Ethical Conduct on the part of the Registered Medical, Practitioner
Chapter: 4.5 Legal Aspect of Medical Records
Legal Aspect of Medical Records
Medical Record is a confidential report of the patient & can not be released without patients permission. Any information from the patients medical records should be released on written request by the patient e.g. to employer or to insurance companies. Police authorities and courts can summon medical records.
How long to preserve the case papers;
Limitation period for filing a case is maximum up to 3 years under the Limitation Act (2 years according to Consumer Protection Act) However, this limitation period starts only after the patient comes to know the effect of the alleged negligence on part of the doctor.
An extreme example can be given of the obstetrician who was sued by the child who was delivered by him and suffered birth injury after 21 years i.e. within 3 years the child becoming major according to the law.
Maharashtra government has issued a resolution (G.R. No. JJH-29 66/49733.~ which states that OPD paper should be kept for 3 years, indoor for 5 years, and papers of Medico Legal Cases for 30 years.
Medical Record is a confidential report of the patient & can not be released without patients permission. Any information from the patients medical records should be released on written request by the patient e.g. to employer or to insurance companies. Police authorities and courts can summon medical records.
How long to preserve the case papers;
Limitation period for filing a case is maximum up to 3 years under the Limitation Act (2 years according to Consumer Protection Act) However, this limitation period starts only after the patient comes to know the effect of the alleged negligence on part of the doctor.
An extreme example can be given of the obstetrician who was sued by the child who was delivered by him and suffered birth injury after 21 years i.e. within 3 years the child becoming major according to the law.
Maharashtra government has issued a resolution (G.R. No. JJH-29 66/49733.~ which states that OPD paper should be kept for 3 years, indoor for 5 years, and papers of Medico Legal Cases for 30 years.
Chapter: 4.4.2 Types of records
1. Investigation reports
Investigation reports form an important part of patient records. Proper preoperative investigation also can help in proving duty of c-are on part of the doctor. Investigations also help in proving the diagnosis and soundness of the treatment. X-rays, ultra sound pictures, ECG records & histopathological reports are irrefutable proof of proper diagnosis & treatment and hence are extremely important medicolegally.
2. Discharge cards
It is important that discharge summary should always co-relate and mirror the case notes of the patient. The discharge cards should always include the instructions to be followed by the patient after his discharge. Example: how to take care of the wound or a limb which is put in a plaster. It should also include the instructions about the follow up visits and in what circumstances the patients should report to the doctor earlier than the routine follow-up.
It happened in one case where the patients hands was put in a plaster by art orthopedic surgeon and the fingers became oedematous & blue due to swelling of the limb & stoppage of circulation. The patient did not report to the doctor as he was told to come back only after 3 week. Since no clear instructions were given to come earlier in these circumstances the case went against the doctor.
In another case, a patient of medical termination of pregnancy, was asked to report after one month, and she failed to do so. In the mean time the MTP failed and pregnancy continued but the doctor was not held negligent as the patient did not report back on time when she could have been offered repeat MTP.
3. Referral notes
The referral note should always include date & time, patient's general conditions, cause of reference and expected course of action to be followed.
It is always wise to keep duplicate copy of the referral note with patient's signature on the same.
In one case a general practitioner referred a patient of jaundice to better equipped general hospital. The patient went there only after 3 days when his condition had deteriorated considerably. When the patient died the relatives alleged that the patient was referred very late but the duplicate referral note preserved by the doctor helped him in proving his innocence.
Reactions after blood transfusion have led to many mishaps. Here/ preserving blood bank receipts as well as blood bottle labels would help.
In a case where serum hepatitis was alleged to have been caused due to blood transfusion, it could be proved by the blood bottle labels that the blood was checked and was free of serum hepatitis antigen.
Video tapes of endoscopic surgeries, electronic fetal heart monitor charts & continuous ECG, have good evidentiary value, in the court of law.
Investigation reports form an important part of patient records. Proper preoperative investigation also can help in proving duty of c-are on part of the doctor. Investigations also help in proving the diagnosis and soundness of the treatment. X-rays, ultra sound pictures, ECG records & histopathological reports are irrefutable proof of proper diagnosis & treatment and hence are extremely important medicolegally.
2. Discharge cards
It is important that discharge summary should always co-relate and mirror the case notes of the patient. The discharge cards should always include the instructions to be followed by the patient after his discharge. Example: how to take care of the wound or a limb which is put in a plaster. It should also include the instructions about the follow up visits and in what circumstances the patients should report to the doctor earlier than the routine follow-up.
It happened in one case where the patients hands was put in a plaster by art orthopedic surgeon and the fingers became oedematous & blue due to swelling of the limb & stoppage of circulation. The patient did not report to the doctor as he was told to come back only after 3 week. Since no clear instructions were given to come earlier in these circumstances the case went against the doctor.
In another case, a patient of medical termination of pregnancy, was asked to report after one month, and she failed to do so. In the mean time the MTP failed and pregnancy continued but the doctor was not held negligent as the patient did not report back on time when she could have been offered repeat MTP.
3. Referral notes
The referral note should always include date & time, patient's general conditions, cause of reference and expected course of action to be followed.
It is always wise to keep duplicate copy of the referral note with patient's signature on the same.
In one case a general practitioner referred a patient of jaundice to better equipped general hospital. The patient went there only after 3 days when his condition had deteriorated considerably. When the patient died the relatives alleged that the patient was referred very late but the duplicate referral note preserved by the doctor helped him in proving his innocence.
Reactions after blood transfusion have led to many mishaps. Here/ preserving blood bank receipts as well as blood bottle labels would help.
In a case where serum hepatitis was alleged to have been caused due to blood transfusion, it could be proved by the blood bottle labels that the blood was checked and was free of serum hepatitis antigen.
Video tapes of endoscopic surgeries, electronic fetal heart monitor charts & continuous ECG, have good evidentiary value, in the court of law.
Chapter: 4.4.1 Types of records
1. Certificates
The various certificates that are issued by the doctor in his professional capacity are:
1. Admission / Discharge certificate
2. Emergency admission certificate
3. Birth record certificate
4. Medical Termination of Pregnancy certificate
5. Maternity certificate
6. Leave certificate
7. Injury certificate
8. Disability certificate.
9. Medico legal case certificate
10. Unsoundness of mind certificate
11. Vaccination certificate
12. Insurance certificate
Giving a false certificate is a criminal offence.
2. Death certificates
Death certificates are extremely important documents and while issuing a death certificate certain precautions have to be taken. A doctor should not issue a death certificate unless he has attended the deceased at least once during the seven days preceding death. One should be very sure of the diagnosis before giving a death certificate. In case of a doubt, it is always better to ask for post mortem examination. While giving a certificate it is important to identify the person concerned and even to note identification marks on the certificate. The certificate should also contain day, date & diagnosis, advice given, signature, name and registration number of the doctor. It is a good practice to keep a duplicate copy of any certificate issued. A doctor is not entitled to charge fees for writing a death certificate. He also can not delay or refuse on the grounds of non receipt of professional fees.
A doctor can refuse to give death certificate if
1. He is not sure of the cause of death
2. It is a sudden death
3. There is suspicion of foul play
4. The death is caused by any violent or unnatural cause, drug, medicine or poison
5. There is suspicion of starvation, exposure or neglect.
In such situation one to has report to police authorities before the body is removed for cremation. Signing of a blank death certificate in anticipation of death is not only illegal but is also violation of medical ethics.
The various certificates that are issued by the doctor in his professional capacity are:
1. Admission / Discharge certificate
2. Emergency admission certificate
3. Birth record certificate
4. Medical Termination of Pregnancy certificate
5. Maternity certificate
6. Leave certificate
7. Injury certificate
8. Disability certificate.
9. Medico legal case certificate
10. Unsoundness of mind certificate
11. Vaccination certificate
12. Insurance certificate
Giving a false certificate is a criminal offence.
2. Death certificates
Death certificates are extremely important documents and while issuing a death certificate certain precautions have to be taken. A doctor should not issue a death certificate unless he has attended the deceased at least once during the seven days preceding death. One should be very sure of the diagnosis before giving a death certificate. In case of a doubt, it is always better to ask for post mortem examination. While giving a certificate it is important to identify the person concerned and even to note identification marks on the certificate. The certificate should also contain day, date & diagnosis, advice given, signature, name and registration number of the doctor. It is a good practice to keep a duplicate copy of any certificate issued. A doctor is not entitled to charge fees for writing a death certificate. He also can not delay or refuse on the grounds of non receipt of professional fees.
A doctor can refuse to give death certificate if
1. He is not sure of the cause of death
2. It is a sudden death
3. There is suspicion of foul play
4. The death is caused by any violent or unnatural cause, drug, medicine or poison
5. There is suspicion of starvation, exposure or neglect.
In such situation one to has report to police authorities before the body is removed for cremation. Signing of a blank death certificate in anticipation of death is not only illegal but is also violation of medical ethics.
Chapter: 4.4 Types of records
Types of records
Case papers can be indoor, or outdoor. Outdoor case papers are usually left with the patients.
Indoor case papers are important documents. Here it is necessary to record detail history and complaints and examination findings of the patient. Some important points which should never be forgotten are the history of allergies; previous surgeries and that of on-going medications.
1 Operation notes
Form an important part of any case records. If post operative complications occur, court will always look at the correctness of steps having been taken during the surgery.
Sometimes, properly written notes of difficult surgeries can protect the surgeon in case of post operative complications. Again, an informed consent form has to be filled in and maintained. It should, however, be remembered that even the most comprehensive consent form does not give a license to a doctor to be negligent in his patient care.
Consent form is only a proof of patient’s agreeing to undergo the legitimate and proper treatment.
2 Prescriptions
A prescription should have a name of the patient and should be dated. It should be legible and properly signed. Before writing a prescription a doctor should confirm that the patient is already not allergic to the same medicine, the side effects and interactions with the other drug. In case of the female patient possibility of conception. Undated prescriptions can be misused and can get the doctor in trouble in a medico-legal situation.
Case papers can be indoor, or outdoor. Outdoor case papers are usually left with the patients.
Indoor case papers are important documents. Here it is necessary to record detail history and complaints and examination findings of the patient. Some important points which should never be forgotten are the history of allergies; previous surgeries and that of on-going medications.
1 Operation notes
Form an important part of any case records. If post operative complications occur, court will always look at the correctness of steps having been taken during the surgery.
Sometimes, properly written notes of difficult surgeries can protect the surgeon in case of post operative complications. Again, an informed consent form has to be filled in and maintained. It should, however, be remembered that even the most comprehensive consent form does not give a license to a doctor to be negligent in his patient care.
Consent form is only a proof of patient’s agreeing to undergo the legitimate and proper treatment.
2 Prescriptions
A prescription should have a name of the patient and should be dated. It should be legible and properly signed. Before writing a prescription a doctor should confirm that the patient is already not allergic to the same medicine, the side effects and interactions with the other drug. In case of the female patient possibility of conception. Undated prescriptions can be misused and can get the doctor in trouble in a medico-legal situation.
Chapter: 4.3 Registers maintained by Hospitals
Registers maintained by Hospitals
Hospitals are also to maintain the following registers:
1. O.P.D register
2. Indoor register
3. Operation theatre register
4. Delivery register
5. Birth & Death register
6. Lab register
7. Radiology including imaging register
8. Nurses GOB register & night report
9. MLC Medico Legal Casey registers
10. MTP (Medical Termination of Pregnancy registers
11. Family planning device register
Various certificates issued by the doctors also form part of medical record.
Hospitals are also to maintain the following registers:
1. O.P.D register
2. Indoor register
3. Operation theatre register
4. Delivery register
5. Birth & Death register
6. Lab register
7. Radiology including imaging register
8. Nurses GOB register & night report
9. MLC Medico Legal Casey registers
10. MTP (Medical Termination of Pregnancy registers
11. Family planning device register
Various certificates issued by the doctors also form part of medical record.
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