Examine, request investigations and diagnose and prescribe treatment for the patient. Document the same in the patient’s OP case file.

In-Patient:
- After initial examination in OPD or emergency the patient is received in the ward/CCU. Resident will provide the admit instructions; write case history, advice on admission.
- Take consent for procedures/enrolment in trials.
- Inform consultant and the patient’s referring doctor about the patient’s conditions.
- Resident will examine patient in each shift and document the patient’s condition with date and time. Inform the consultant if there is any change in the patient’s condition.
- Patient’s condition may have to be reviewed and documented more often.

In CCU/ICCU:
- Resident will give the request for investigation, blood and blood products.
- Resident will document the reference for cross consultation with a brief clinical note and reason for reference and discuss with referred consultant telephonically or personally and document the opinion.
- Record reports of investigations in investigation chart,



investigation done in other centers and result of procedures done in cath lab.
- Resident will accompany patient to outside lab to monitor patient’s status till return to Heart Centre.
- Chart the medication legibly (preferably with generic name) with strength, dose, frequency and mode of administration stated correctly. Signature must be affixed after the order.
- The resident must sign request for medicines from the pharmacy.
- Changes in medication and line of treatment must be corroborated with reason in the case note.
- Resident will write a Transfer out/Transfer in note when a patient is shifted from or to CCU/ICCU.
- Transfer out/discharge patient must have the consent/authorization by consultant and the resident must document the discharge order.
- Resident will write the discharge/death summary and ensure that the Registrar or Consultant verifies it and sign the typed summary.
- On discharge of a patient, the

📌 Ward & Icu Rmo (Mumbai)
🏢 Brahma Kumari’s Global Hospital and Research Centre
📍 Mumbai