Eye Hospital : Procedure on destruction of medical records

 

Documented procedures are in place on retaining the patient’s clinical records, data and information

SOP for Retention of Patient Record, Data & Information.
Sr. No.	Process Flow	Responsibility
1	The records are stored for the following retention period for patients records: 1.     IPD Patients records – 5 years 2.     OPD patients Records – 1 year ( Henceforth ) 3.     Medical Legal Records – Life time 4.     Death Records – Life time The non-patient records are retained for the following period of time: 1.     Various registers like auto-clave, fumigation – 2 years. 2.     OT / IPD Register – 5 years	Administration
2	The access to patient record is restricted.	Manager & Medical Director
3	The storing location is protected from dampness, leakages & rodent. Pest control is done once in three months.	Manager & Medical Director
4	During safety rounds this area is particularly seen for appropriateness.	Manager & Medical Director

Various records, data and information are stored under lock and key and not accessible to anyone without due authorization. The room in which it is stored is protected from rodents, dampness, leakage, theft and is under Pest Control Contract.

The destruction of medical records, data and information is in accordance with the laid down procedures

  

SOP for Destruction of Patient Record, Data & Information.
Sr. No.	Process Flow	Responsibility
1	At the end of the retention period, a list of obsolete record is prepared.	Manager & Medical Director
2	A notice is displayed at the reception and newspaper indicating the intention of ...................Hospital to destroy medical records of a particular period.	Manager & Medical Director
3	An appeal in above is made to patients desiring to collect the records within one month.	Manager & Medical Director
4	At the end of the above referred period, the record is destroyed by shredding in front of at least two responsible employees of ...................Hospital and one member from general society.	Manager & Medical Director
5	Record of above is maintained.	Manager & Medical Director

 

 

Eye Hospital : Define process to whom the patient record can be released

 

Documented procedures are in place on retaining the patient’s clinical records, data and information

SOP for Retention of Patient Record, Data & Information.
Sr. No.	Process Flow	Responsibility
1	The records are stored for the following retention period for patients records: 1.     IPD Patients records – 5 years 2.     OPD patients Records – 1 year ( Henceforth ) 3.     Medical Legal Records – Life time 4.     Death Records – Life time The non-patient records are retained for the following period of time: 1.     Various registers like auto-clave, fumigation – 2 years. 2.     OT / IPD Register – 5 years	Administration
2	The access to patient record is restricted.	Manager & Medical Director
3	The storing location is protected from dampness, leakages & rodent. Pest control is done once in three months.	Manager & Medical Director
4	During safety rounds this area is particularly seen for appropriateness.	Manager & Medical Director

Various records, data and information are stored under lock and key and not accessible to anyone without due authorization. The room in which it is stored is protected from rodents, dampness, leakage, theft and is under Pest Control Contract.

The destruction of medical records, data and information is in accordance with the laid down procedures

 

 

 

 

SOP for Destruction of Patient Record, Data & Information.
Sr. No.	Process Flow	Responsibility
1	At the end of the retention period, a list of obsolete record is prepared.	Manager & Medical Director
2	A notice is displayed at the reception and newspaper indicating the intention of .................Hospital to destroy medical records of a particular period.	Manager & Medical Director
3	An appeal in above is made to patients desiring to collect the records within one month.	Manager & Medical Director
4	At the end of the above referred period, the record is destroyed by shredding in front of at least two responsible employees of .................Hospital and one member from general society.	Manager & Medical Director
5	Record of above is maintained.	Manager & Medical Director

 

 

Eye Hospital : Documented procedures exist for retention time of medical records, data and information

 

Documented procedures are in place on retaining the patient’s clinical records, data and information

SOP for Retention of Patient Record, Data & Information.
Sr. No.	Process Flow	Responsibility
1	The records are stored for the following retention period for patients records: 1.     IPD Patients records – 5 years 2.     OPD patients Records – 1 year ( Henceforth ) 3.     Medical Legal Records – Life time 4.     Death Records – Life time The non-patient records are retained for the following period of time: 1.     Various registers like auto-clave, fumigation – 2 years. 2.     OT / IPD Register – 5 years	Administration
2	The access to patient record is restricted.	Manager & Medical Director
3	The storing location is protected from dampness, leakages & rodent. Pest control is done once in three months.	Manager & Medical Director
4	During safety rounds this area is particularly seen for appropriateness.	Manager & Medical Director

Various records, data and information are stored under lock and key and not accessible to anyone without due authorization. The room in which it is stored is protected from rodents, dampness, leakage, theft and is under Pest Control Contract.

The destruction of medical records, data and information is in accordance with the laid down procedures

 

SOP for Destruction of Patient Record, Data & Information.
Sr. No.	Process Flow	Responsibility
1	At the end of the retention period, a list of obsolete record is prepared.	Manager & Medical Director
2	A notice is displayed at the reception and newspaper indicating the intention of ..........Hospital to destroy medical records of a particular period.	Manager & Medical Director
3	An appeal in above is made to patients desiring to collect the records within one month.	Manager & Medical Director
4	At the end of the above referred period, the record is destroyed by shredding in front of at least two responsible employees of ..........Hospital   and one member from general society.	Manager & Medical Director
5	Record of above is maintained.	Manager & Medical Director

 

Eye Hospital : Documented policies and procedures for maintaining confidentiality, integrity and security of records, data and information

 

Documented procedures exist for maintaining confidentiality, security and integrity of information as mentioned below.

SOP for maintaining Confidentiality, Security and Integrity of information.
Sr. No.	Process Flow	Responsibility
1	The patients are the owners of their medical record and in no form it should be made available to any third party without written authorization from the patient. Medical records are stored by the staff. Access to the Medical Record is limited to authorized staff.	Asst. Manager /Receptionist
2	The patient’s relatives require written authorization from the patient to obtain information from the medical record. The administrator or members of the Quality team (for audit reasons), or court-of-law or police (for legal reasons) may have access to information within medical record with an approved written request. The patients and the TPAs (for financial reasons) are given,(if needed) Xerox copies while retaining the original with the establishment.	Asst. Manager & Staff
3	Once the patient is discharged from RDEH, the medical records are stored in the Hospital.	Asst. Manager
4	The Reception Staff is responsible for proper storage, retrieval, and maintenance of confidentiality and security of the record.	Reception Staff
5	The Administrator is the overall supervisor of the medical records, from generation, storing, until destruction. All the staff members are equally responsible for maintaining integrity of the record while generating or handling it.	Asst. Manager & All Staff
6	The record means both in paper or digital form whether they are generated inside or sourced from outside. The integrity, confidentiality needs to be maintained in both the cases.	Asst. Manager
7	The Staff is informed that the record is the property of the RDEH and cannot be parted with to anyone at any cost. In case of violation, legal action can be initiated. Management views any violation with zero tolerance and staff is made aware about this policy.	Asst. Manager

 

Privileged health information is used for the purposes identified or as required by law and not disclosed without the patient’s authorization. This information is useful while executing treatment plan and various precautions to be taken during this process.