DOCUMENTATION AND AUDIT IN PRASUTI TANTRA & STREE ROGA

DOCUMENTATION AND AUDIT IN PRASUTI TANTRA & STREE ROGA

• Documentation and audit are vital components in clinical practice to ensure quality, safety, transparency, and evidence-based outcomes in Prasuti Tantra and Stree Roga.

• Proper documentation helps in medico-legal safety, continuity of care, research, and academic purposes.

• Audit allows critical assessment of healthcare delivery systems and implementation of clinical improvements.

IMPORTANCE OF DOCUMENTATION IN AYURVEDA AND MODERN OBSTETRICS-GYNAECOLOGY

• In Ayurveda, classical texts emphasize Roga Pariksha, Rogi Pariksha, Doshavastha, and Upashaya-Anupashaya documentation.

• In modern practice, documentation is a mandatory part of patient records, informed consent, diagnostics, and treatment outcomes.

📜 Sanskrit Reference:
“रोगिणां व्यसनं ह्येतत् रोगज्ञानेन सिध्यति।
रोगज्ञानं तु तत्सर्वं चिकित्सायामुपेक्ष्यते॥”
(Charaka Samhita, Sutrasthana 10/4)
Meaning: Proper understanding and recording of disease leads to correct treatment.

TYPES OF DOCUMENTATION IN PRASUTI TANTRA & STREE ROGA

• CLINICAL DOCUMENTATION

  • Patient history: Menstrual, obstetric, contraceptive, surgical, personal, dietary

  • Examination findings: General, systemic, pelvic

  • Doshika involvement: Vataja, Pittaja, Kaphaja Lakshanas

  • Prakriti, Vikriti analysis

  • Classical Lakshanas: Yonivyapad, Artava Dushti, Garbhini Pariksha

• DIAGNOSTIC DOCUMENTATION

  • Panchavidha Pariksha: Darshana, Sparshana, Prashna, etc.

  • Lab tests: CBC, urine, hormonal assays, USG, CTG, PAP smear

  • Imaging findings and interpretations

• THERAPEUTIC DOCUMENTATION

  • Ayurvedic treatments like Yonidhavana, Pichu, Varti, Kashaya Dhara

  • Modern treatments: Antibiotics, hormonal therapy, D&C, hysterectomy

  • Procedures: MTP, tubectomy, caesarean section

• OBSTETRIC RECORDS

  • Antenatal checkups: Weight, BP, fetal heart rate, fundal height

  • Labour notes: Stages, per vaginal examination findings

  • Delivery summary and neonatal outcome

• SURGICAL & PROCEDURAL DOCUMENTATION

  • Indications, techniques, intraoperative notes

  • Consent forms, postoperative care instructions

• INFORMED CONSENT DOCUMENTATION

  • Written and signed documentation of patient understanding and acceptance of diagnosis, procedures, risks, alternatives

• DISCHARGE SUMMARY & REFERRAL NOTES

  • Summary of diagnosis, treatment, outcome, advice for follow-up

IMPORTANCE OF DOCUMENTATION IN MEDICO-LEGAL CONTEXT

• Protection in court cases related to negligence, maternal mortality, malpractice.

• Legal record of consent, refusal, and procedures conducted.

📜 Sanskrit Reference:
“यस्य विज्ञानमस्तीह स न मुञ्चति कर्हिचित्।
अविज्ञाय चिकित्सेति स हि मुञ्चति नात्र संशयः॥”
(Ashtanga Hridaya Sutrasthana 1/23)
Meaning: One who treats without understanding the disease puts the patient at risk.

MEDICAL AUDIT IN PRASUTI TANTRA & STREE ROGA

• Definition: A systematic, critical analysis of the quality of clinical care, procedures, outcomes, and documentation.

• OBJECTIVES OF AUDIT

  • Improve patient care and outcomes

  • Identify strengths and deficiencies in practice

  • Implement evidence-based practices

  • Enhance training and institutional development

• TYPES OF AUDITS

  • Clinical Audit: Quality of diagnosis, treatment, follow-up

  • Process Audit: Adherence to SOPs and protocols

  • Outcome Audit: Maternal and fetal outcomes

  • Prescription Audit: Rationale and accuracy of medicines prescribed

  • Ayurvedic Intervention Audit: Efficacy of Yonikarma, Prasava procedures

• STEPS IN CONDUCTING AN AUDIT

  • Identify the topic and standards

  • Data collection and review

  • Analysis and comparison with benchmarks

  • Report generation and corrective action

  • Re-audit to assess improvements

RELEVANT MODERN POINTS FROM OBSTETRICS AND GYNAECOLOGY TEXTBOOKS

• Documentation Standards (From Williams Obstetrics / D.C. Dutta):

  • SOAP Format: Subjective, Objective, Assessment, Plan

  • WHO Antenatal card maintenance

  • Obstetric risk scoring and checklist-based care

• Audit Indicators:

  • Maternal mortality rate, C-section rate, infection rate

  • NICU admission, perinatal mortality, postpartum complications

  • Audit of infertility workup and ART protocols

  • Audit of cervical cancer screening compliance

INTEGRATION OF AYURVEDIC AND MODERN DOCUMENTATION PRACTICES

• Combine Rogi-Roga Pareeksha with standardized patient case sheets.

• Document outcomes of classical therapies with validated tools.

• Use both Sanskrit and English terminologies for dual referencing.

• Maintain Prasuti Pariksha, Stree Dosha Lakshanas, and Upashaya records parallel to USG reports, hormonal profiles.

📜 Sanskrit Reference:
“सिद्धं तु चिकित्सितं येन स कार्यो वैद्य उत्तमः।
असिद्धं यदि तत्रापि सिद्धिहेतुः चिकित्सकः॥”
(Charaka Samhita, Vimana Sthana 8/88)
Meaning: Success or failure in treatment depends on the physician's skills and documentation is part of that skill.