qualifications/ training/ experience/ designation on the prescription. Qualifications mean recognized
degrees/ diplomas as regulated by the Indian Medical Degrees Act, 1916 as amended from time to time. Mention of
scholarships/ membership/ awards which are no qualifications should be avoided.
Always mention date and timing of the consultation.
Mention age and sex of the patient. In a pediatric prescription weight of the patient must also be mentioned.
Always put your hand on the part that the
patient/ attendant says is painful. Apply your stethoscope on him, even if for cosmetic reasons.
If, after completing the examination, the
patient/ attendant feels that something has been left out or wants something to be examined, oblige him.
Always face the patient. Do not stare. Some patients tolerate very little eye contact. Learn to observe out of the corner of our eyes.
In case you have been
distracted/ inattentive during the history taking, ask the patient/
attendant to start all over again. He will never mind it. As far as possible consultations should not be interrupted for non-urgent calls.
Ask the patient to come back for review the next day, in case you have examined him hurriedly or if you are not sure about the
Mention “diagnosis under review” until the diagnosis is finally settled.
In complicated cases record precisely history of illness and substantial physical findings about the patient on your prescription.
If the patient/
attendants are erring on any count (history not reliable, refusing investigations, refusing admission) make a note of it or seek written refusal preferably in local language with proper witness.
Mention the condition of patient in specific/objective terms. Avoid
vague/ non-specific terminology.
Record history of drug allergy.
Write names of drugs clearly. Use correct dosages (by revising knowledge periodically) and mention clearly method and interval of administration. Here one must use local or sign language. Do not forget writing precautions like
Ast./ p.c./ a.c./ locally/ with milk/ h.s.etc. in local language.
If a drug is a poison (e.g., certain local applications), warn in writing.
Mention additional precautions, e.g., food, rest, avoidance of certain drugs, allergens, alcohol, smoking, etc., if indicated.
Give instruction to the patient in comprehensible terms, making sure that the patient understands both the instruction and the importance of strictly adhering to them, e.g., while prescribing to potent anti-inflammatory drug, warn that if he experience any stomach trouble he should stop taking the drug and consult a doctor immediately.
Mention likely side-effects, and action to be taken if they occur.
Remember to advise in writing pathological
tests/ radiological tests at specified intervals for certain drugs which require such monitoring if such drugs are prescribed. Some examples are: Sodium Valporate, Carbamezapine, Gold Salts, Methotrexate and other
immuno-suppressives, Chloramphemicol, etc.
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