> #legal-documents-in-hospital-documentation > Discuss legal documents that are used in hospital documentation and their know abbreviation in Kenya?
Dennis Kipkirui
Nov 15, 2023

Discuss legal documents that are used in hospital documentation and their know abbreviation in Kenya?


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Nov 15, 2023
In Kenya, there are several legal documents that are used in hospital documentation. These documents are essential for ensuring proper patient care, record-keeping, and legal compliance. Some of the commonly used legal documents in hospitals in Kenya include:

1. Patient Admission Form (PAF): This document is used to record the patient's personal information, medical history, and reason for admission. It also includes consent for treatment and disclosure of medical information.

2. Consent Form: This form is used to obtain the patient's informed consent for specific medical procedures, surgeries, or treatments. It outlines the risks, benefits, and alternatives to the proposed intervention.

3. Medical Examination Report (MER): This document is used to record the findings of a medical examination, including vital signs, physical examination findings, and initial diagnosis.

4. Treatment Plan: This document outlines the proposed treatment course for the patient, including medications, therapies, and interventions. It may also include details about follow-up appointments and referrals.

5. Discharge Summary: This document is prepared when a patient is discharged from the hospital. It includes information about the patient's condition at discharge, medications prescribed, follow-up instructions, and any necessary referrals.

6. Death Certificate: This legal document is issued by a medical practitioner to certify the cause of death. It includes details such as the date, time, and location of death, as well as the underlying cause and contributing factors.

7. Medical Consent for Minors: This form is used when obtaining consent for medical procedures or treatments involving minors. It requires the signature of a parent or legal guardian.

Abbreviations for these documents may vary depending on the hospital or healthcare facility. However, some commonly used abbreviations in Kenya include:

- PAF: Patient Admission Form
- CF: Consent Form
- MER: Medical Examination Report
- TP: Treatment Plan
- DS: Discharge Summary
- DC: Death Certificate
- MCM: Medical Consent for Minors

It is important to note that accurate and complete documentation is crucial in healthcare settings to ensure patient safety, continuity of care, and legal compliance.

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