IMS med records

1. NABH IMS –PREACCREDITATION ENTRY LEVEL

2.  PATIENT
 THE DOCTOR
 HOSPITAL ADMINISTRATORS.
 MEDICO LEGAL PURPOSES.
 EXTERNAL REPORTING

3.  NAME OF PATIENT
 FATHER’S / HUSBAND’S NAME
 AGE & SEX
 OCCUPATION
 PERMANENT / EMERGENCY ADDRESS.
 TELEPHONE / MOBILE NUMBERS
 NATIONALITY
 RELIGION
 MEDICO LEGAL CASE IF ANY.


4.  INITIAL ASSESSMENT AND REASSESSMENT SHEET SHEET
 PROGRESS AND TREATMENT RECORD
 NURSING ASSESSMENT AND REASSESSMENT SHEET
 DIFFERENT INVESTIGATIONS REPORT FORMS


5.  MEDICATION RECORD
 T.P.R. CHART.
 INTAKE AND OUTPUT RECORD FORM.
 CRITICAL CARE SHEET
 PAC/OTNOTES/OT NURSING NOTE/POST OP
NOTES/ANESTH NOTES
 CONSENT
 NUTRITIONAL RECORD
 PATIENT EDUCATION SHEET
 DISCHARGE SUMMARY
 DEATH INTIMATION FORM
 VALUABLES HANDOVER FORM

6.  HR DEPT DOES COMPETENCY ASSESSMENT
 BASED ON QUALIFICATIONS AND EXPERIENCE
 CREDENTIALLING IS DONE AND AUTHORIZATION FOR
PERFORMANCE OF DUTIES IS GIVEN
 HOSPITAL POLICY BASED ON CREDENTIALLING COMMIITEE
RECOMMENDATIONS

7.  EACH ENTRY IN HOSPITAL RECORD HAS TO BE IDENTIFIABLE
 REQUIRES NAME DATE AND TIME ALONG WITH SIGNATURE

8.  .THE CONTENTS OF THE MED RECORD ARE IN CONSONENCE
WITH THE HOSPITAL POLICY AND THE PREVAILING LAWS
 THE FORMATS AND FORMS ARE APPROVED BY THE HOSPITAL
COMMITTEE AND THEN USED FOR MEDICAL RECORD
 ALL ENTRIES ARE TO BE SIGNED WITH NAME AND DATE AND
TIME

9.  THE MEDICAL RECORD HAS RECORD OF OPD
ASSESSMENTS,INTIAL ASSESSMENT IN WARD,REASSESSMENTS
BY DOCTOR AND NURSE
 IT IS A DATE WISE RECORD OF ALL ASPECTS OF CARE

10.  EACH ASSESSMENT IS FOLLOWED BY A PROVISIONAL
DIAGNOSIS AND A PLAN OF CARE
 SUPPORTING REASONS FOR PLAN OF CARE ARE DOCUMENTED
 ALL RESULTS OF INVESTIGATIONS ETC ARE RECORDED

11.  RECORD OF ALL OPERATION RELATED ACTIVITY ARE
DOCUMENTED
 SURGICAL ASSESSMENT WITH DIAGNOSIS AND PLAN OF CARE
 PAC/SSCHECKLIST
 OP NOTES/INTRA OP MONITORING RECORD/ANESTHESIA
RECORD
 CONSENT
 PORT OP NOTES AND PLAN OF CARE.

12.  A COPY OF THE DISCHARGE NOTE DULY SIGNED BY DOCTOR
IS KEPT IN MED RECORD - AFTER SIGNED BY PATIENT
 THE DISCHARGE NOTE CONTAINS ALL RELEVANT DETAILS OF
THE IPD CARE AND FOLLOW UP CARE

13.  DEATH INTIMATION FORM IS FILLED ON DEATH OF A PATIENT
 DEATH CERTIFICATE COPY IS KEPT IN MED RECORD WHICH
INCLUDES RELEVANT DETAILS OF DEATH
 INTIMATION OF DEATH IS SENT TO CONCERNED GOVT DEPT
 A COPY OF HANDING TAKING OVER OF BODY WITH DETAILS
OF ID MARKS AND IDENTIFIED BY AND NAMES OF
ATTENDENTS IS DOCUMENTED
 COPY OF VALUABLES HANDING OVER OF PATIENT TO
ATTENDENT IS ALSO ENDORSED

14. PATIENT RECORD IS CONFIDENTIAL
ACCCESS IS GIVEN ONLY TO CARE PROVIDER AFTER WRITTEN
REQUEST TO MRD FOR PAST RECORDS
ONLY PATIENT OR AUTHORISED REP HAS ACCESS TO MEDICAL
RECORDS
INSURANCE COMPANIES WHO HAVE FUNDED THE TREATMENT
ALSO HAVE ACCESS TO RECORDS

15.  MRD MANUAL HAS POLICIES ANDD PROTOCOLS OF THE
HOSPITAL
 RECORDS ARE KEPT IN A SAFE AND SECURE AND LOCKED
PLACE
 IT SHOULD BE PROTECTED FROM FIRE
,MOISTURE,RODENTS,UNAUTHORIZED ACCCESS
 ONLY AUTHORIZED PERSONS CAN ACCCESS MED RECORDS

16. PATIENTS INFO IS CONFIDENTIAL
ONLY THE FOLLOWING CAN ACCESS RECORD
PATIENT
CAREGIVER
AUTHORISED REP
NOK IN CASE OF DEATH
INSURANCE COMPANY
MRD AUTHORISED PERSONS.
COURT OF LAW

17.  DOCUMENTED POLICIES AND PROCEDURES GUIDE RETENTION
TIME OF RECORDS
 MLC RECORD
 DEATH RECORDS
 OPD RECORDS
 LAMA/DOR PATIENT RECORDS
 ALSO BIRTH AND DEATH RECORD
 ALL ACCORDING TO HOSPITAL MRD COMMITTEE REGULATION
WHICH FOLLOW LATEST REGULATIONS

18.  THE RETENTION PROCEDURES FOR MEDICAL RECORD
ARE AS PER HOSPITAL POLICY
 CONFIDDENTIALITY IS MAINTAINED FOR THE PATIENTS
INFO.
 SECURITY FOR THE MRD ROOM AND MOVEMENT OF
RECORDS IS MAINTAINED
 A MRD DOCUMENT TRACER CARD IS MAINTAINED
 NOBODY CAN TAKE DOCU WITHOUT PROPER
AUTHORIZATION

19.  THE MRD COMMITTEE DECIDES AND DOCUMENTS HOSPITAL
POLICY FOR DESTRUCTION OF MEDICAL RECORDS,DATA AND
INFORMATION ACCORDING TO THE PREVAILING LAWS
 A COMMIITEE IS SET UP FOR THE DESTRUCTION OF RECORDS