Document everything you do-Marar


Concept of OCMU & SOAP lucidly explained
An excellent symposium on Maintenance of Medical Records was organized recently by Central India Nephrology Society at Chitnavis Centre, Nagpur. Dr.Anup Marar, Director (Administration), Orange City Hospital & Research Institute delivered the keynote address while Dr.Ashutosh Apte, Shri.Chandrakant Bhosale and Dr.V.L.Gupta were the faculty members. Dr.Lokendra Singh and Dr.Deepak Deshmukh chaired various sessions. At the outset, Dr.Dhananjay Ookalkar welcomed the gathering.
Dr.Anup Marar explained that records should be objective, consistent, meaningful and useable (OCMU). Moreover the need of all doctors, nurses to regularly write SOAP notes (Subjective, Objective, Assessment, Plan) after each examination and round is desired as archives and records management share a simple goal of providing for organizational & individual accountability. Accountability depends on being able to demonstrate managed access to information which is important for reasons of ongoing need or future evidence, from the time of its creation.
Document everything you do; as it is your documentation which is only going to be of any use later, he added. He conveyed that at OCHRI nobody is expected to follow oral instructions. There has to be an accountability of directives either upwards, downwards or in sideways communication. This maintains answerability and transparency.