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OG35.12-13,OG38.4 | Discharge, Referral and Medical Certification — SDL Guide (Part 3)
Supervised Practice: Drafting Clinical Documents
Competency in clinical documentation is built through supervised practice — writing real or simulated documents and having them reviewed by a faculty member before they are filed or issued. The NMC competency framework places OG35.12, OG35.13, and OG38.4 at the 'should help' (SH) level, meaning the student performs the task under supervision rather than independently. During your OG clinical posting, each of the three document types should be practised as follows.
For the discharge summary, identify a patient being discharged from the postnatal ward or gynaecology ward. Under the guidance of your resident or consultant, write a complete discharge summary from the case record. Before submitting it to the faculty for review, self-check against the mandatory components: Is every medication listed with its dose? Is the follow-up date specific? Are red-flag symptoms listed? Have neonatal details been included for postnatal cases? Your resident will compare your draft with the information in the case record and provide structured feedback. Common resident feedback points include: incomplete medication lists, vague follow-up instructions ('return in 6 weeks' without a date), and missing neonatal immunisation records.
For the referral letter, identify a case being referred from your unit — an eclamptic patient being transferred to a higher centre, or a gynaecological malignancy being referred for oncology input. Draft the referral letter before observing the resident write the actual one. Compare your draft with the resident's version: where did you undergrade or overgrade urgency? Did you include all the investigation results the receiving unit will need? Were the haemodynamic parameters and treatment given clearly stated?
For the medical certificate, practise with simulated cases: a postnatal patient needing a maternity certificate, a patient with fibroid uterus needing a sickness certificate, and a case in which you must decide whether you have legal authority to certify (e.g. a patient requesting a certificate for an ESI claim but the examination was not done by you). Walk through the decision pathway with your faculty: What Act governs? Am I the right person to sign? Have I personally examined the patient today? Do I use a prescribed form?
The bedside clinic is the appropriate setting for all three skills. Make it a habit to request feedback on documentation quality from every resident and consultant you work with — documentation rarely receives as much supervision as clinical procedures, but its impact on patient outcomes is equally great.
SELF-CHECK
During your OG posting, a patient with severe pre-eclampsia is being transferred to the medical college from the primary health centre. The referral letter states: 'BP high, refer for further management.' What is the most important additional information the receiving team needs that is missing?
A. The patient's educational background
B. The haemodynamic parameters, any treatment given, gestational age, IV access status, and urgency grading
C. The patient's insurance status
D. The name of the village health worker
Reveal Answer
Answer: B. The haemodynamic parameters, any treatment given, gestational age, IV access status, and urgency grading
For an obstetric emergency referral, the receiving team needs: current blood pressure and pulse, gestational age, any treatment already given (e.g. MgSO4 loading dose, timing, and dose), intravenous access status, oxygen saturation, and an explicit urgency marking. 'BP high, refer for further management' provides none of this actionable clinical information and puts the receiving team at a disadvantage in triage.
Self-Assessment
The questions below are designed to help you consolidate your learning across all three documentation domains covered in this module — discharge summaries, referral letters, and medical certification. Self-assessment at this stage is not about memorising lists; it is about applying the principles of accuracy, completeness, timeliness, legibility, confidentiality, and the medicolegal framework to realistic clinical situations. For each question below, pause and formulate your own answer before reading further. Then compare your response with a resident or faculty member during your next bedside clinic session. The objective is to identify gaps in your reasoning — particularly around gestational thresholds under the MTP Act 2021, the legal authority to issue different certificate types, and the specific information required in an emergency obstetric referral. These are the domains where students most commonly lose marks in OSCE and viva assessments, and they are also the domains where documentation errors cause the most serious patient harm.
- A woman with gestational hypertension is being discharged on labetalol 100 mg twice daily and aspirin 75 mg once daily at night. Write out the medication section of her discharge summary as you would actually complete it on the ward, including all fields required by your institution's discharge template.
- You are at a primary health centre when a primigravida at 36 weeks presents with BP 160/110, severe headache, and 2+ proteinuria. The centre has no MgSO₄. You decide to refer her immediately to the district hospital. What are the five pieces of information your referral letter must include that are specific to an obstetric emergency transfer?
- A 32-year-old woman, married, presents at 22 weeks with a severe fetal anomaly detected on morphology scan. She requests an MTP. Under the MTP Act 2021: (a) Is she eligible? (b) How many registered medical practitioners must certify the opinion? (c) What must the certificate state?
- A patient's employer (an ESI-registered firm) asks you to backdate a sickness certificate by one week because the patient missed an appointment during that time. Outline your legal obligations and what you should document.
Discuss your answers with a resident or faculty member during your bedside clinic session.