SOP for Retention of Patient Record, Data & Information (MRD)

SOP for Retention of Patient Record, Data & Information (MRD)
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  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 – 2 years. 2.   IPD Register – Life Time	Administration
2	The access to patient record is restricted.	Administrator & Director
3	The storing location is protected from dampness, leakages & rodent. Pest control is done once in six months.	Administrator & Director
4	During safety rounds this area is particularly seen for appropriateness.	Administrator & Director

SOP for maintaining Confidentiality, Security and Integrity of Patient information MRD

SOP for maintaining Confidentiality, Security and Integrity of Patient 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.	Administrator /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.	Administrator & Staff
3	Once the patient is discharged from JBCC, the medical records are stored in the MRD Deptt.	Administrator
4	The MRD Staff is responsible for proper storage, retrieval, and maintenance of confidentiality and security of the record.	MRD 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.	Administrator & 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.	Administrator
7	The Staff is informed that the record is the property of the JBCC 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.	Administrator

SOP Release of Patients Information

SOP Issue of Medical Record

SOP for Condemnation Scrap disposal of Biomedical Equipment & Instruments.

SOP for Destruction of Patient Record, Data & Information.

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.	Administrator & Medical Director
2	A notice is displayed at the reception and newspaper indicating the intention of VJEH to destroy medical records of a particular period.	Administrator & Medical Director
3	An appeal in above is made to patients desiring to collect the records within one month.	Administrator & 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 VJEH and one member from general society.	Administrator & Medical Director
5	Record of above is maintained.	Administrator & Medical Director

SOP for Retention of Patient Record, Data & 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.	Administrator & Medical Director
3	The storing location is protected from dampness, leakages & rodent. Pest control is done once in three months.	Administrator & Medical Director
4	During safety rounds this area is particularly seen for appropriateness.	Administrator & Medical Director

SOP for maintaining Confidentiality, Security and Integrity of information.

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 authorised staff.	Administrator /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.	Administrator & Staff
3	Once the patient is discharged from VJEH, the medical records are stored in the Hospital.	Administrator
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.	Administrator & 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.	Administrator
7	The Staff is informed that the record is the property of the VJEH 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.	Administrator

SOP for Operation & Maintenance (preventive & breakdown)

SOP for Operation & Maintenance (preventive & breakdown)
Sr. No.	Process Flow	Responsibility
1	All the machines are listed in equipment register and the maintenance plan is prepared. Some of the equipment are under AMC or under warranty or on call basis. This status is mentioned in the equipment register& the label.	BME Administrator
2	All the equipment have associated history card.	BME Administrator
3	At the beginning of the month, the BME/ administrator lists down the equipment which are due for servicing in that month.	BME Administrator
4	At the convenience of the operator of the equipment, a servicing date is fixed.	BME Administrator
5	After the equipment is serviced, the operator ensures that the same is working properly and the servicing report is handed over to the administrator.	Administrator
6	The administrator records the details in the relevant register.	Administrator
7	For important equipment a history card is filled mentioning date of servicing done and next due date is put.	Administrator
8	Whenever equipment is malfunctioning or completely stopped functioning, the operator informs the administrator who in turn summons the servicing agency to do the needful.	Administrator
9	After the equipment is repaired the operator ensures that it is back to normalcy and collects and hands over the servicing/repair report to the administrator.	Administrator
10	Suitable entries are made in history card.	Administrator