Clinical settings.
WHERE THE REAL BENEFIT IS
Administration. Documentation, letters, summaries and coding consume clinical time that should go to patients.
WHAT IT MUST NOT DO
Diagnose Determine treatment Advise on medication Replace examination
FOR CLINICAL NOTES
A draft from your dictation, reviewed and corrected before entering the record.
Verify medications, doses, allergies and the plan every time.
FOR PATIENT INFORMATION
"Explain [condition] for a patient with no medical background."
Then verify every clinical statement before it reaches anyone.
FOR REFERRAL AND DISCHARGE LETTERS
Genuinely useful, and check the medication list every time.
That is the highest-risk element.
FOR CONFIDENTIALITY
Do not put identifiable patient information into a general service.
Remove names, dates of birth and record numbers.
FOR LOCAL GUIDANCE
Nigerian clinical guidelines and drug availability may not be reflected.
Use local sources.
