Medical Records checklist
and quality indicators for NABH accreditation preparation
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 sheets
3. 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. Specialty specific assessment findings
c. Nursing assessment of patient and care
plan(identification of nursing needs, special requirements of patients,
identification of vulnerable patient etc.)
d. Nutritional screening to identify nutritional
needs of patient, if any.
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
c. Safety checklist to prevent surgical errors
(like WHO surgical safety checklist)
d. Informed consent (refer point no. 11 also)
e. Operative note by the surgeon or his/her team
member
f. Post-operative plan of care
15. Informed consent in medical records should
contain following
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 records