QUALITY INDICATORS REPORT- MRD

MONTH: JAN-2019
Sr. No Indicator Name Data Description
Time for Initial Assessment for Indoor Patient
1a Numerator for the assessment
Denominator indoor
Time for Initial Assessment for Emergency Patient
1b Numerator for the assessment
Percentage of cases(In patient where in careDenominator
plan with emergency
desired outcome is documented and countersigned by No of in patients case
2 clinician) Numerator been documented
records where in the
Denominator Total
nutrionalofassessment
no patients
Percentage of cases (in-patients) wherein screening for has been
nutritional needs has been done. documented
3 Numerator
Denominator Total no of patients
Percentage of cases (in-patients) wherein the nursing
care plan is documented been documented
4 Numerator
Denominator Total no of patients
Percentage of medication charts with error prone
abbreviations prone abbreviations
11 Numerator
Denominator chart reviewed
Mortality Rate
31 Numerator month
Denominator deaths
Percentage of medical records not having discharge
summary summary
63 Numerator
Denominator deaths
Percentage of medical records not having codification as
per international classification of diseases (ICD) ICD
64 Numerator
Denominator deaths
Percentage of medical records having incomplete and/or
improper consent consent
65 Numerator
Denominator deaths
Percentage of missing records
66 Numerator No of missing records
Denominator No of records
Appropriate handovers during shift change - Doctors (per
patient per shift) done appropriately
67a Numerator
Denominator opportunities
Appropriate handovers during shift change-Nurses (per
patient per shift) done appropriately
67b Numerator
Denominator opportunities
Compliance rate to Medication prescription in capitals
70 Numerator capital letters
Denominator prescriptions

Name Of Department In-Charge : Sr. Nirali Patel / Sr.Ranjitha sandip

Sign Of Department In- Charge;
Date 03/11/2019
ORS REPORT- MRD
JAN-2019
DATA FIELD (To be filled Calculated Values Traceability to
by Department In charge) NABH Standards

725 1.10
662
CQI3A
150 2.00
75

300
40.71
737
129 Day
608 82.50 care pts
737 Nutrition
Assessment
700 94.9796472185
737

150 20.35
737
CQI 3h
12 1.66
724

3 00.41
724 CQI 4g

0 00.00
724

325 44.89
724

1 0.14 Patel
737

1089 25.62 CQI 3g

4250

3961 93.20 CQI 3g

4250

121 16.42
737

Name of Accreditation Co-ordinator

Sign of Accreditation Co-ordinator
03/11/2019
 QUALITY INDICATORS REPORT- MRD
MONTH: FEB-2019
Sr. No Indicator Name Data Description
Time for Initial Assessment for Indoor Patient
1a Numerator for the assessment
Denominator indoor
Time for Initial Assessment for Emergency Patient
1b Numerator for the assessment
Percentage of cases(In patient where in careDenominator
plan with emergency
desired outcome is documented and countersigned by No of in patients case
2 clinician) Numerator been documented
records where in the
Denominator Total
nutrionalofassessment
no patients
Percentage of cases (in-patients) wherein screening for has been
nutritional needs has been done. documented
3 Numerator
Denominator Total no of patients
Percentage of cases (in-patients) wherein the nursing
care plan is documented been documented
4 Numerator
Denominator Total no of patients
Percentage of medication charts with error prone
abbreviations prone abbreviations
11 Numerator
Denominator chart reviewed
Mortality Rate
31 Numerator month
Denominator deaths
Percentage of medical records not having discharge
summary summary
63 Numerator
Denominator deaths
Percentage of medical records not having codification as
per international classification of diseases (ICD) ICD
64 Numerator
Denominator deaths
Percentage of medical records having incomplete and/or
improper consent consent
65 Numerator
Denominator deaths
Percentage of missing records
66 Numerator No of missing records
Denominator No of records
Appropriate handovers during shift change - Doctors (per
patient per shift) done appropriately
67a Numerator
Denominator opportunities
Appropriate handovers during shift change-Nurses (per
patient per shift) done appropriately
67b Numerator
Denominator opportunities
Compliance rate to Medication prescription in capitals
70 Numerator capital letters
Denominator prescriptions

Name Of Department In-Charge : Sr. Nirali Patel / Sr.Ranjitha sandip

Sign Of Department In- Charge;
Date 14/03/19
ORS REPORT- MRD
FEB-2019
DATA FIELD (To be filled Calculated Values Traceability to
by Department In charge) NABH Standards

1012 1.48
683
CQI3A
100 1.52
66

359
47.93
749
50 Files
699 93.32 Nurtition
749 Assessment
Incomplete
732 97.7303070761
749

100 13.35
749
CQI 3h
10 1.38
726

2 00.28
726 CQI 4g

0 00.00
726

300 41.32
726

0 0.00
749

2965 74.13 CQI 3g

4000

3956 98.90 CQI 3g

4000

100 13.35
749

Name of Accreditation Co-ordinator

Sign of Accreditation Co-ordinator
14/03/19
 QUALITY INDICATORS
Mar-19
REPORT- MRD
Sr. No Indicator Name Data Description
Time for Initial Assessment for Indoor Patient
1a Numerator for the assessment
Denominator indoor
Time for Initial Assessment for Emergency Patient
1b Numerator for the assessment
Percentage of cases(In patient where in careDenominator
plan with emergency
desired outcome is documented and countersigned by No of in patients case
2 clinician) Numerator been documented
records where in the
Denominator Total
nutrionalofassessment
no patients
Percentage of cases (in-patients) wherein screening for has been
nutritional needs has been done. documented
3 Numerator
Denominator Total no of patients
Percentage of cases (in-patients) wherein the nursing
care plan is documented been documented
4 Numerator
Denominator Total no of patients
Percentage of medication charts with error prone
abbreviations prone abbreviations
11 Numerator
Denominator chart reviewed
Mortality Rate
31 Numerator month
Denominator deaths
Percentage of medical records not having discharge
summary summary
63 Numerator
Denominator deaths
Percentage of medical records not having codification as
per international classification of diseases (ICD) ICD
64 Numerator
Denominator deaths
Percentage of medical records having incomplete and/or
improper consent consent
65 Numerator
Denominator deaths
Percentage of missing records
66 Numerator No of missing records
Denominator No of records
Appropriate handovers during shift change - Doctors (per
patient per shift) done appropriately
67a Numerator
Denominator opportunities
Appropriate handovers during shift change-Nurses (per
patient per shift) done appropriately
67b Numerator
Denominator opportunities
Compliance rate to Medication prescription in capitals
70 Numerator capital letters
Denominator prescriptions

Name Of Department In-Charge : Sr. Nirali Patel / Sr.Ranjitha sandip

Sign Of Department In- Charge;
Date 20/05/19
ORS
r-19
REPORT- MRD
DATA FIELD (To be filled Calculated Values Traceability to
by Department In charge) NABH Standards

CQI3A
#DIV/0!

290
30.33
956
51 Day
905 94.67 care pts
956 Nutrition
Assessment
956 100
956

200 20.92
956
CQI 3h
14 1.47
955

2 00.21
955 CQI 4g

0 00.00
955

489 51.20
955

0 0.00
955

3054 66.84 CQI 3g

4569

4560 99.80 CQI 3g

4569

200 20.92
956

Name of Accreditation Co-ordinator

Sign of Accreditation Co-ordinator
20/05/19
 QUALITY INDICATORS REPORT- MRD
MONTH: APRIL-2019
Sr. No Indicator Name Data Description
Time for Initial Assessment for Indoor Patient
1a Numerator for the assessment
Denominator indoor
Time for Initial Assessment for Emergency Patient
1b Numerator for the assessment
Percentage of cases(In patient where in careDenominator
plan with emergency
desired outcome is documented and countersigned by No of in patients case
2 clinician) Numerator been documented
records where in the
Denominator Total
nutrionalofassessment
no patients
Percentage of cases (in-patients) wherein screening for has been
nutritional needs has been done. documented
3 Numerator
Denominator Total no of patients
Percentage of cases (in-patients) wherein the nursing
care plan is documented been documented
4 Numerator
Denominator Total no of patients
Percentage of medication charts with error prone
abbreviations prone abbreviations
11 Numerator
Denominator chart reviewed
Mortality Rate
31 Numerator month
Denominator deaths
Percentage of medical records not having discharge
summary summary
63 Numerator
Denominator deaths
Percentage of medical records not having codification as
per international classification of diseases (ICD) ICD
64 Numerator
Denominator deaths
Percentage of medical records having incomplete and/or
improper consent consent
65 Numerator
Denominator deaths
Percentage of missing records
66 Numerator No of missing records
Denominator No of records
Appropriate handovers during shift change - Doctors (per
patient per shift) done appropriately
67a Numerator
Denominator opportunities
Appropriate handovers during shift change-Nurses (per
patient per shift) done appropriately
67b Numerator
Denominator opportunities
Compliance rate to Medication prescription in capitals
70 Numerator capital letters
Denominator prescriptions

Name Of Department In-Charge : Sr. Nirali Patel / Sr.Ranjitha sandip

Sign Of Department In- Charge;
Date 05/11/2019
ORS REPORT- MRD
PRIL-2019
DATA FIELD (To be filled Calculated Values Traceability to
by Department In charge) NABH Standards

721 1.09
662
CQI3A
150 2.00
75

200
27.14
737
109 Day
628 85.21 care pts
737 Nutrition
Assessment
205 27.815468114
737

95 12.89
737
CQI 3h
13 1.80
724

3 00.41
724 CQI 4g

0 00.00
724

217 29.97
724

1 0.14 Patel
737

1089 25.62 CQI 3g

4250

3961 93.20 CQI 3g

4250

121 16.42
737

Name of Accreditation Co-ordinator

Sign of Accreditation Co-ordinator
05/11/2019
 QUALITY INDICATORS REPORT- MRD
MONTH OF MAY-2019
Sr. No Indicator Name Data Description
Time for Initial Assessment for Indoor Patient
1a Numerator for the assessment
Denominator indoor
Time for Initial Assessment for Emergency Patient
1b Numerator for the assessment
Percentage of cases(In patient where in careDenominator
plan with emergency
desired outcome is documented and countersigned by
2 clinician) Numerator been documented
Denominator Total no of patients
Percentage of cases (in-patients) wherein screening for
nutritional needs has been done. documented
3 Numerator
Denominator Total no of patients
Percentage of cases (in-patients) wherein the nursing
care plan is documented been documented
4 Numerator
Denominator Total no of patients
Percentage of medication charts with error prone
abbreviations prone abbreviations
11 Numerator
Denominator chart reviewed
Mortality Rate
31 Numerator month
Denominator deaths
Percentage of medical records not having discharge
summary summary
63 Numerator
Denominator deaths
Percentage of medical records not having codification
as per international classification of diseases (ICD) ICD
64 Numerator
Denominator deaths
Percentage of medical records having incomplete
and/or improper consent consent
65 Numerator
Denominator deaths
Percentage of missing records
66 Numerator No of missing records
Denominator No of records
Appropriate handovers during shift change - Doctors
(per patient per shift) done appropriately
67a Numerator
Denominator opportunities
Appropriate handovers during shift change-Nurses (per
patient per shift) done appropriately
67b Numerator
Denominator opportunities
Compliance rate to Medication prescription in capitals
70 Numerator capital letters
Denominator prescriptions

Name Of Department In-Charge : Sr. Nirali Patel / Sr.Ranjitha sandip

Sign Of Department In- Charge:
Date 14/6/2019
ORS REPORT- MRD
MAY-2019
DATA FIELD (To be filled by Calculated Values Traceability to
Department In charge) NABH Standards

1178 1.14
1030
CQI3A
267 1.31
204

347
33.92
1023

889 86.90
1023

826 80.742913001
1023

112 10.95
1023
CQI 3h
7 0.68
1023

0 00.00
1023 CQI 4g

0 00.00
1023

291 28.45
1023

0 0.00
1023

1419 20.83 CQI 3g

6812

5534 81.24 CQI 3g

6812

208 20.33
1023

Name of Accreditation Co-ordinator

Sign of Accreditation Co-ordinator
14/06/2019
 QUALITY INDICATORS REPORT- MRD
MONTH OF JUNE-2019
Sr. No Indicator Name Data Description
Time for Initial Assessment for Indoor Patient
1a Numerator for the assessment
Denominator indoor
Time for Initial Assessment for Emergency Patient
1b Numerator for the assessment
Percentage of cases(In patient where in careDenominator
plan with emergency
desired outcome is documented and countersigned by
2 clinician) Numerator been documented
Denominator Total no of patients
Percentage of cases (in-patients) wherein screening for
nutritional needs has been done. documented
3 Numerator
Denominator Total no of patients
Percentage of cases (in-patients) wherein the nursing
care plan is documented been documented
4 Numerator
Denominator Total no of patients
Percentage of medication charts with error prone
abbreviations prone abbreviations
11 Numerator
Denominator chart reviewed
Mortality Rate
31 Numerator month
Denominator deaths
Percentage of medical records not having discharge
summary summary
63 Numerator
Denominator deaths
Percentage of medical records not having codification
as per international classification of diseases (ICD) ICD
64 Numerator
Denominator deaths
Percentage of medical records having incomplete
and/or improper consent consent
65 Numerator
Denominator deaths
Percentage of missing records
66 Numerator No of missing records
Denominator No of records
Appropriate handovers during shift change - Doctors
(per patient per shift) done appropriately
67a Numerator
Denominator opportunities
Appropriate handovers during shift change-Nurses (per
patient per shift) done appropriately
67b Numerator
Denominator opportunities
Compliance rate to Medication prescription in capitals
70 Numerator capital letters
Denominator prescriptions

Name Of Department In-Charge : Nehal Christian

Sign Of Department In- Charge:
Date 07/10/2019
ORS REPORT- MRD
JUNE-2019
DATA FIELD (To be filled by Calculated Values Traceability to
Department In charge) NABH Standards

1009 1.08
932
CQI3A
171 1.35
127

287
31.64
907

721 79.49
907

776 85.5567805954
907

102 11.25
907
CQI 3h
2 0.22
907

1 00.11
907 CQI 4g

0 00.00
907

221 24.37
907

0 0.00
907

1129 19.61 CQI 3g

5756

4952 86.03 CQI 3g

5756

187 20.62
907

Name of Accreditation Co-ordinator

Sign of Accreditation Co-ordinator
07/10/2019