PRE-ACCREDITATION ENTRY LEVEL

STANDARDS FOR HCO & SHCO

SESSION #2

BASIC PROGRAM TO TRAIN CPQIH

INFORMATION MANAGEMENT SYSTEM (IMS)

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 Summary of Standards
IMS 1
Medical record
management (5)

lMS4 Information IMS2

Retention and management system Contents
destruction (3) (IMS) (6)

IMS 3
Confidentiality and
security (2)

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 Information Management
Patient
Administration
Management
Specialist
Management
Services
Information
Management
HIMS
Support
Patient Care
Services
Management
Management
Finance and
Administration
Management

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 Intent of IMS

The NABH Information Management System (IMS) chapter aims at:

 Continued improvement is dependent to a large extent on the information
generated, stored and utilized appropriately by the organisation.
 Goal is to ensure that required inputs are available to the right personnel.
 Applies equally to both manual/digital based information system.

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 IMS 1: The organisation has a complete and
accurate medical record for every patient.

IMS 1a: Every medical record has a unique identifier.

IMS 1b: Organisation identifies those authorised to make entries in medical record.
IMS 1c: Every medical record entry is dated and timed.
IMS 1d: The author of entry can be identified.
IMS 1e: The contents of medical record are identified and documented.

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 Contents of Medical Record

 Admission record.
 Initial assessment form.
 Progress notes.
 Medication charts.
 IO charts.
 TPR sheets.
 Consent forms.
 Discharge summary.

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 How to implement IMS1?

Medical record Documentation

 Assign UHID or CR number.  Identify authorised personnel.

 Manual entry: Write UHID on all sheets.  Define documentation policy.
 Electronic records: Label entries with  Document all entries immediately.
same UHID.  Discuss variances.
 Identify contents of medical records.  Devise and implement
 Audit to ensure all entries are dated, corrective/preventive actions.
timed and are signed by authorised  Train staff on chart
personnel. documentation.

Note: In case of electronic records, automatic generation of date and time by the system is
preferable.

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 SNDT

Every entry in medical records

should have signature, date, name of
author and time of entry.

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 Best Practices for Identifying Author of an Entry

 Write name/employment number/affix

stamp.
 Cross check with the list of initials and
author names in the master document.
 In electronic records, link username and
password to the author’s name.
 Enable provision for electronic
signature.

Note: Periodic audits should be conducted to ensure that the authors are identifiable.

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 What should be documented in the apex manual?

 Policy on documenting medical

record.
 List of authorised personnel.
 List of sheets in the medical record
and their purpose.

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 IMS 2: The medical record reflects continuity of care.

IMS 2a: The record provides an up to date and chronological account of patient care.
IMS 2b: The medical record contains information regarding reasons for admission,
diagnosis and plan of care.
IMS 2c: Operative and other procedures performed are incorporated in medical
record.
IMS 2d: The medical record contains a copy of the discharge note duly signed by
appropriate and qualified personnel.
IMS 2e: In case of death, the medical record contains a copy of the death certificate
indicating the cause, date and time of death.
IMS 2f: Care providers have access to current and past medical record.

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 Patient Care Plan

Patient Care Plan

 Desired outcome.

 Preventive aspect.

 Curative aspect.

 Rehabilitative aspect.

Note: The care plan should be periodically reviewed (At least once in 24 hours).

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 Procedure/Surgery Notes

All procedures / surgeries performed on the

patient shall include:
 Presenting complaints.
 Provisional diagnosis.
 Site of surgery.
 Surgical procedure in brief.
 Details of implants used, if any.
 Post-op orders.
 Further care plan.

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List of modes of dying that should not
be mentioned as cause of death:
 Cardiac arrest.
 Cardiopulmonary arrest.
 Respiratory arrest.
 Respiratory failure.
 Failure to thrive.
 Multi organ/System failure.

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 How to implement IMS2?

Filing Issuing

 Organise records of case sheets  Issue medical record on

sequentially. request and after
 Place sheet that is currently in use authorisation.
on top.  Maintain inward-outward
 Follow hospital’s policy for register or devise tracer card
system.
arranging case sheets of discharged
 Note reason for issuance and
patients.
date, time of issue and return.
 Insert note for missing sheet.
 Identify missing records and
 Place deficiency checklist in front.
retrieve to the MRD.
 Audit to identify missing record.

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 How to implement IMS2?

Assessment forms Pre and post op forms

 Doctor: Document reason for  Enclose filled consent forms.

admission.  Place surgical safety checklist.
 Nurse: Include intended plan of  Write procedure notes.
patient care.
 MRD: Do ICD 10 coding
of diagnosis.

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 How to implement IMS2?

Discharge summary Death summary

 Doctor: Document reason for  Physician: Indicate underlying

admission. cause of death and intervening
 Treating doctor: Document conditions.
final diagnosis.  Primary/treating consultant:
 Treating consultant: Sign Sign death summary.
discharge summary prepared
by RMO.

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 Points to Remember
Medical records Doctors and MRD personnel

 Write description of all aspects of

patient care.
 Make entries with date and time.  Undergo training on
 Fill identified sheets. documentation.
 Document mandatory information  Conduct chart
(MLC cases), provisional diagnosis and reviews/audit.
reasons for ordering investigations.

Note: The hospital should ensure that complete and up-to-date medical records
are available 24/7.

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 IMS 3: Documented policies and procedures are in
place for maintaining confidentiality, integrity and security of records,
data and information.

IMS 3a: Documented policies and procedures exist for maintaining confidentiality,
security and integrity of information.
IMS 3b:Privileged health information is used for purposes identified or as required
by law and not disclosed without the patient’s authorisation.

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 Definitions

Medical Records Officer (MRO) is the overall

supervisor of medical records from the
time it reaches the MRD till its destruction.
Privileged health information refers to
information about the health record that
could help in identifying the patient. It
includes patient’s history, current health
status, the diagnosis and treatment
provided.

Note: Privileged health information can be used as required by laws or purposes

identified.

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 Disclosure of Information to Government
Agencies

 MLC reporting.
 Birth and death.
 Notifiable diseases.
 Child, adult or domestic abuse.
 Judicial and administrative
proceeding.

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 How to implement IMS3?

Access control Data confidentiality

 MRD: Maintain list of authorised staff.  Maintain confidentiality of

 Medical records: Give access to medical records.
authorised staff.  Ensure non-disclosure of
 Electronic records: Maintain hierarchy privileged health information.
of access control/editing rights.
 Give photocopy of medical record to
patient on request (within 72 hours).
 Track chart movement using tracer
method.

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 How to implement IMS3?

Data security Patient information

 Access data in secure manner.  Provide insurance company access to

 Protect data. patient’s health records.
 Restrict and limit copying of  Send medical records of discharged
electronic records. patients to MRD.
 Conduct audit trails to track  Hand over medical records for
electronic records. study/research purpose.
 Backup electronic records.  Share/report mandatory information
 Keep MLC records under lock to government agencies.
and key.  Adopt appropriate mechanisms to
ensure 24/7 access to patient records.

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What should be documented in the apex manual?

 Policies for MRD and IP in apex

manual.
 Policy for privileged health
information.

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 IMS 4: Documented policies and procedures exist
for retention time of records, data and information

IMS 4a: Documented policies and procedures are in place on retaining the patient’s
clinical records, data and information.
IMS 4b: The retention process provides expected confidentiality and security.
IMS 4c: The destruction of medical records , data and information is in accordance
with the laid down procedure.

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 Destruction Protocol

 Identification of medical records to be

destroyed.
 Approval procedure for destruction.
 Notification before destruction, if
required.
 Method of destroying the medical
records.
 Information about destroyed medical
records.

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 How to implement IMS4?

Retention Destruction

 Define time frame in  Define protocol in

consonance with laws and consonance with laws.
regulations.  Shred and dispose manual
 Retain patient records longer records.
than prescribed time.

Note: Do not destroy medical record before the prescribed retention time.

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 What should be documented in the apex manual?

 Retention policy.
 Protocol for destroying medical record.
 List of destroyed medical records.
 Date of destruction.

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Any
Questions

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THA N K
YO U!