Medical Records of patient is the most important record that a hospital maintains. Contents in medical records serves as an important evidence of compliance to many NABH standards and objective elements. For a hospital that is preparing for NABH accreditation, concentrating on medical records is very important. Here is the list of things that must be ensured to comply with accreditation requirements.
(Please note that this checklist is meant for documentation and organizing of medical records and not meant for treatment audit or medical audit)
1. Medical record of each patient should have a unique identification number.
2. Unique identification number of the medical record should be printed/written on every sheet inside the medical record to prevent misplacement of sheets3. If applicable, MLC identification and number and details should be mentioned on medical record
4. Medical record should contain general consent of the patient in all admissions
5. Medical records of currently admitted patients must contain documented initial assessment within the time-frame defined by hospital (maximum 24 hours). The documented initial assessment should include following;
a. Assessment of presenting complaints, vital signs (temperature, pulse, BP and respiration) and salient examination findings
b. Speciality specific assessment findings
c. Nursing assessment of patient and care plan(identification of nursing needs, special requirements of patients, identification of vulnerable patient etc.)
e. Diagnosis (Final or Provisional)
f. Plan of care, which includes treatment plan, preventive aspects of care and desired result of care)
6. Initial assessment record should have name, signature, date and time
7. Plan of care should be signed / counter-signed by consultant in-charge of the patient
8. Medical records should contain results of tests carried out, the care provided and re-assessment findings
9. If patient is transferred to other hospital, medical records should contain date of transfer, reason of transfer and name of receiving hospital
10. Each entry in medical records should be signed, named, dated and timed
11. Entries in medical records should be legible
12. Medication orders and charts should not have any non-standard abbreviations. Or should have only those abbreviations that are defined by the hospital
13. Entries in medical records should be up-to-date
14. Medical records of Patients who have undergone surgery should contain following documentation
a. Pre-operative assessment
b. Type of anesthesia and anesthetic medications used
b. Type of anesthesia and anesthetic medications used
e. Operative note by the surgeon or his/her team member
f. Post-operative plan of care
a. Information on the surgical procedure, risks, benefits, alternatives, name of the doctor who will perform surgery
b. Informed consent should be in language that patient understand (having a bi-lingual consent form can be of help)
c. Consent form signed by patient (or guardian if applicable)
d. Consent form signed by the doctor taking consent
e. Consent form signed by an independent witness
16. Medical records of discharge patients should contain following documents
a. Discharge summary (refer point no. 14 also)
b. Death summary in case of deaths (should mention cause of death)
c. Final diagnosis of the patient
d. ICD coding on the file within a defined timeframe
e. In case of autopsy, a copy of autopsy report
17. Discharge summary of patient should contain following documentation
a. Patient’s name, demographic details and unique identification number
b. Date of admission and date of discharge
c. Reason of admission, significant findings, diagnosis and patient’s condition as the time of discharge
d. Information regarding investigation results, any procedure performed, medication administered and other treatment given
e. Follow up advice, medication and other instructions
f. Instruction on when to obtain urgent care
g. Instruction on how to obtain urgent care
18. Safety, security and confidentiality of medical records. Medical records department should additionally take care of following points,
a. Sufficient and safe storage for medical records
b. Regular pest control in medical record storage area
c. Availability of fire extinguisher near-by and knowledge on how to use the same
d. Policy of who can access medical records
e. How to respond to different request for accessing medical records
f. Mechanism to quickly retrieve the medical records
g. ICD codification
h. Screening of medical records
Quality Indicators Medical Records:
1. Percentage of medical records in which plan of care is documented and countersigned
2. Percentage of medical records in which nursing care plan is documented
3. Percentage of medication chart with error prone abbreviations
4. Percentage of medical records not having ICD codes
5. Percentage of medical records not having discharge summary
6. Percentage of medical records having incomplete/improper consent
7. Percentage of missing
Other checklist of use for accreditation preparation:
Note: The checklist is open for improvement. Please suggest, if you think any important point has been missed.
