Role and responsibilities of Duty Doctor (RMO) in NABH hospital

Role & Responsibilities of Duty Doctor (RMO) for IPD Files as per NABH Standards

✅ 1. Initial Assessment & Admission Note

• Perform initial assessment within defined time (usually within 1 hour of admission).

• Document patient’s history, clinical findings, provisional diagnosis, and treatment plan clearly in IPD file.

• Ensure admission note is signed with name, designation, date & time.

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✅ 2. Daily Progress Notes

• Record daily progress notes including vitals, examination, treatment given, patient condition, and plan.

• Ensure notes are legible, dated, timed, and signed as per NABH record-keeping standards.

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✅ 3. Implementation of Doctor’s Orders

• Check and implement consultant’s orders promptly.

• Record time of implementation and note if any order is not carried out with reasons.

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✅ 4. Medication Documentation

• Cross-check medication charts, verify dose, route, frequency before writing.

• Document administration details where applicable and ensure medication reconciliation at admission, transfer, and discharge.

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✅ 5. Consent Documentation

• Ensure informed consent forms are completed before any procedure/treatment requiring consent.

• Confirm patient understanding and document witness signatures where needed.

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✅ 6. Critical Event Documentation

• Record all critical events, incidents, complications, or sudden changes in patient condition immediately.

• Inform the consultant and document timing of intimation.

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✅ 7. Handover Notes

• During duty change, handover to incoming doctor with proper documentation in IPD file to maintain continuity of care.

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✅ 8. Discharge Summary Preparation

• Assist in drafting discharge summary, ensuring it includes:

  • Diagnosis (final)

  • Treatment given

  • Procedures done

  • Condition at discharge

  • Medications advised

  • Follow-up instructions

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✅ 9. LAMA / Absconding / Death Notes

• In case of LAMA, absconding, or death, document detailed notes, inform family, complete all formalities as per hospital policy.

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✅ 10. Adherence to Documentation Policies

• Ensure legibility, completeness, and authentication of all entries.

• Do not overwrite; in case of errors, strike through with a single line, write correction, and sign with date/time.

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✅ 11. Compliance with Hospital Policies

• Follow all NABH and hospital policies related to IPD documentation, infection control, patient safety, and confidentiality.

Mr. Naveen Kumar Prajapati

Medical Record Officer

Fatima Hospital Padri Bazar Gorakhpur

naveenp702@gmail.com

Mo-9415473284