GABA HOSPITAL

YAMUNA NAGAR

Manual of Operations
Medical records Section

Gaba Hospital, Yamuna Nagar Manual of Operations Document No.

 Medical Records Section GH/MRD/NABH
Date 15/03/2019
Revision No. 00

Manual of Operations
Medical records Section
Service Name Medical records

Date Created 01/07/2017

Approved By Medical Director

Name: Dr. Nikhil Bansal

Signature
Reviewed By In chargeMedical Records Section

Name : Dr.Ripudaman Gaba

Signature

Issued By Quality Cell

Name : Ashok Kumar

Signature

Responsibility of Updating Technical In charge medical Records Section

Name :

Signature
Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical Records Section GH/MRDNABH
Date 15/03/2019
Revision No. 00

Table of Contents

Order Particulars

A Purpose/Objective(s)

B Responsibility

C Scope and location

D Modalities

E Departmental Policy(ies)

F Documentation

G Retention period

H Quality Assurance
Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical Records Section GH/MRD/NABH
Date 15/03/2019
Revision No. 00

A. Objective(s):
 To determine the accuracy of documentation
 To keep records complete , accessible for research and other purposes including
medico legal
 To provide confidentiality, integrity, security and ensure their safe keeping
 To follow the law of the land as well as hospital’s policies
 To meet the information needs of the stakeholders

B. Responsibility:

In charge of the section

C. Scope:

 In patient files
 Out patient records – Casualty OPD
 Medicolegal case sheets
 Birth registers
 Death Registers
 Any other as ordered by management from time to time

Location :

Easily accessible to the patients and staff within the hospital

D. Modalities

All indoor and OP records as applicable including death and medicolegal records. Records of
medical examination if any will also be kept

E. Departmental Policies :
 Access control
 Prevention against tampering
 Not to issue to any one without proper authorization
 Record of destruction to be maintained life long
 Maintaining completeness of records
Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical Records Section GH/MRD/NABH
Information Needs Date 15/03/2019
Revision No. 00

Identification of information needs of the hospital and procedure to meet these needs

All data transmitted through mail, verbally, online transmission, hard copies,
circulars as per requirement and as the case may be

Information needs of MRD : Source of data/information Frequency ( can also

be as desired )
 Daily census Nursing Head/Manger IT
 Bed Occupancy rate-category Daily
Nursing Head/Manger IT
wise
 Daily admissions-category wise Daily
 Daily
discharges/LAMA/Deaths/ML Admissions/Manager IT
cases etc.
Daily
 Communicable diseases data
for onward transmission to
relevant stakeholders Discharge cell/NS/Manager IT
 No. of operations /procedures Daily
unit/consultant wise Infection control Nurse/Dept. of
microbiology

OT Manager/Manger IT Daily/ as desired

Daily

Information needs of
management:
 Daily/Monthly bed occupancy In charge MRD/Manger IT Daily/monthly or as
rate- category wise: Total in desired by Mgt.
patient days *100/Total IP days
as per beds As desired
 Bed turnover rate : Total Do
deaths and discharges/No. of As desired
functional beds Do
 Bed turn over interval: Total As desired
staffed bed days-Total occupied
days/In patient D +d As desired
Do
 Average length of stay : Total in
patient days(daily census)/D+d
 Mortality Rate: Total no. of Do Daily
death in given time/ D+d
 New admissions/discharges/ Do Daily /monthly/SOS
operations-procedures
performed Head Finance As desired
 Daily /Monthly revenue from
different sections e.g. beds, Head Finance As desired
Labs etc.
Respective HoDs As desired
 Revenue generated department
wise e.g. lab, imagings , OT etc. Head Finance As desired
 Non payments
 Income expenditure statement Head Finance Annually
 Budgetary and non budgetary
expenses Do Monthly
 Annual Budget
 Employee Do As desired
attrition/absenteeism
 Any new requirements for any HRD Monthly
resource
 Cost of bad quality Respective HoDs Real Time
 Any major complaint by any
Head Finance Real Time
employee or any stakeholder /
news items about the HCO PRO/Administrator on duty

 Any VIP movement Security Real time

 Any major unrest amongst HRD Real Time

employees

Legal Head
 Any statutory non compliances
PRO/Quality/Finance Real Time
 Any major audit by any external
agency

Real
Time/Monthly /as
 Any major breach of discipline HRD desired
by any of the employees
Real Time/as desired
 Any litigations/pending cases in Legal
courts or other statutory
authorities
Real Time/Monthly
 Any major infrastructure Head Maintenance
problem
As desired
 Quantum of free services
provided Head Finanace
  Participation in community out
reach programmes PRO/Marketing

 Vendor Satisfaction Purchase and store head monthly/SOS

 Quality Indicators Head Quality Monthly

Monthly/SOS

Policy :

 Divulge the relevant data/ information to the relevant stakeholder

/statutory authorities within stipulated time as applicable with due
permission from competent authorities. The original record will not be
handed over except to the police/court/any other regulatory body though it
can be shown in records section only under supervision. Endeavor would be
to generate data through HIS

Procedure:

 The requisitioner asks for a particular data/information on a predefined

structured format/application with justification
 The permission is granted by the competent authority after due
consideration and the request is marked to the concerned person /HoD
 The data/ information is given under the acknowledgment and clause of
confidentiality that it will not be used for any other purpose than asked for.
The person handing over the records/ data should also be identifiable by his
signature/name
 The medical records should also be marked as how many times this
particular record has been accessed and by whom.
 Person handing over the data /file will first see the previous access to the
records and if doubtful will bring it to the notice of management
 No change in data/ information is permitted without permission of head of
the institution
 Even Doctors are not allowed to take original files out side the section
Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical Records Section GH/MRD/NABH
Information Needs –Contd. Date 15/03/2019
Revision No. 00

Information needs of the

consultants

 Access to current medical

records

Available with nursing staff (on SOS

 Access to past medical records rounds)

 Data for Research

MRD
SOS

MRD/IT head
SOS
Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical Records Section GH/MRD/NABH
Document Control Date 15/03/2019
Revision No. 00
Page 3 of 8
Document Control
Policy: All documents are standardized , authorized and stamped as “controlled Document”, periodically
updated , meet all stakeholders’ requirements and easy for any type of analysis. Policies are authorized by
the HoD along with head of Institution

Procedure :

Creation of Document (form/format/ policies and procedures)

 The document is created by the end user/quality department keeping in view the
requirements of accrediting agencies/insurance or other regulatory bodies and the best
practices available in literature. They are so designed that that the final analysis is easy
and relevant and meets the requirements.

Reviewing for adequacy

 The document thus created will be put up to a particular committee or HoD or any other
competent authority for brain storming . The changes if any or made and finally approved
with date of approval . A copy of the approved DFA is preserved for at least till further up
date. The authorized policies and procedures are disseminated to the concerned
departments/persons , training given and implementation monitored and the same are
incorporated in the SOPs
 The forms/ formats are given a unique code no. and sent for printing. Once printed the
new ones are in place and older are withdrawn from all locations and archived. Such
archiving is done for a period of at least three years or till next update whichever is later.
Date of implementation of any document is noted clearly

Review for updation

 The inventory of any of the printed formats/forms should never be more than 6 months
and at every next order the contents must be reviewed by the concerned person for any
amendments or the concerned person immediately informs stationery department well in
advance about the amendments to be made so that it is not missed at the time of reorder
for printing

Storage and Retention and retrieval of filled up forms/formats/ Data

 The forms or formats which form the content of patient medical record will be destroyed
along with them as per policy. All others containing raw data are kept for a period of at
least 1 year or as per specific stipulated requirements but throughout stored safely in
departments whether in physical or electronic form to be accessed after due authorization

Recognition

 All such documents bear the stamp” Controlled Document” and are kept in a custody of
an authorized person

Dissemination: of data/ Information would be done as described in Information Needs

Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical records Section GH/MRD/NABH
Authors of entry, contents of Date 15/03/2019
medical record : use of Revision No. 00
abbreviations

Persons authorized to make entry in Patient Medical Records:

Policy ;

The following persons are authorized to make entry in patient medical records clearly
and legibly and will be named, signed, ( for easy identification of author of entry)dated
and timed there and then immediately after assessment/ procedure e.g. post-operative
notes/ procedure notes. Consent to be signed beforehand

 Doctors
 Nurses
 Physiotherapists
 Clinical Psychologist
 Nutritionist

Contents of Patient Medical Record:

 Discharge Summary / Death summary/ Death Certificate

 Registration
 General Consent
 Financial Counselling
 Letter from Dr. advising admission
 Initial assessment by Dr
 Initial assessment by nurses
 Nutritional assessment
 Progress Notes
 Nursing daily assessments and vitals monitoring
 Various consent forms/ PAC form
 Post operative notes
 PADSS
 Surgical Safety Checklist
 Any referral summary/ Death summary
 Investigation reports

Use of Abbreviations:
Policy :
The HCO allows only the following abbreviations to be used only for indoor patient records (
known to nurse)entries but not in discharge summaries and OP slips or any referral slips,
However doctors/ nurses encouraged to do away with all abbreviation as far as possible
BD Twice a day
TDS Thrice a day
SOS Whenever needed
hs At night time
Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical records Section GH/MRD/NABH
Confidentiality, Integrity, Date 15/03/2019
Security of medical records Revision No. 00

Policy :
The MRD to have access control with no unauthorized entry and changes if any required in medical
records due to inadvertent entry to be updated only after approval of competent authority

Procedure:

The files complete in all respects are received by MRD , indexed and stored safely throughout their
retention period keeping their integrity intact through protection from pests, rodents, termite,
dampness ,perforated racks and easy access to fire extinguisher fixed out side . All records are kept
off the floor even for a short while Access to files is always through authorization and following set
procedure after obtaining necessary documentary proof for confidentiality purpose

The record will only be given keeping in view the doctrine of privileged communication and given
only after written authorization of consumer of service if he/ she himself/ herself is not available

The tracer card is used while retrieving the file

There is access control to medical records section for safety from pilferage and tampering – Original
not given to any one except regulatory authorities that too after photocopying it

The authorized computer operator is not to divulge the password to anyone else under any
circumstance

Every accessed record has a documentary proof

Death and MLC files are stored separately in locked almirahs

RTI information is given as per law after approval from hospital authorities

The current medical records are always available at nursing counter and past can be accessed
from medical records section after due procedure as laid by the management
Gaba Hospital, Yamuna Manual of Operations Document No. GH/MRD/PE
Nagar Medical records Section Date 01/07/2017
Issuance Medical Patient Revision No. 00
Records to various Page 4 of 8
stakeholders
Medical Records Requisition Form
1. Full Name of requisitioner:
2. Permanent address with phone no.:
3. Address for correspondence with phone number:
4. Relationship with patient:
5. Patient Details:

Name:
Age/Sex
Registration No.
6. Documents required
---------------------------------------------------------------------------------------

7. Purpose
a. ----------------------------------------------------------------------------------------
----
b. ----------------------------------------------------------------------------------------
----

8. Self attested photocopy of a photo ID—Ration card/ voter card/ passport / driving
license/ Aadhar card submitted

Signature and name of requisitioner Signature of authorizing person of the

hospital
Date and Time Date and Time

Signature and name of issuing person

Date and Time
Issue register serial no.

Acknowledgement by requisitioner (Name-sign-date and time)

Pl. note : This form in original to be kept in patient medical record file after issuance of the
requisitioned records . The original medical record will not be issued to any one except the statutory
authorities. The doctors will also not be issued original but can be shown in the department itself ,
however they can be given photocopy if they so desire

Pl. retain this copy in medical record

Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical Records Section GH/MRDNABH
Retention of patient Medical Date15/03/2019
Records Revision No. 00

Medical Records Requisition Form

For Doctors

Name:

Designation:

Department:

Details of record required:

Purpose:

Name and Signature of Dr. :

Approval by competent authority of Hospital:

Record shown by :

Date and Time :

Pl. Note ; Original record will not be issued however it can be seen in MRD
section itself or photocopy can be given

Pl. retain this copy in patient medical record

Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical Records Section GH/MRDNABH
Retention of patient Medical Date15/03/2019
Records Revision No. 00

Policy :

As per law and if there are two conflicting circulars these are retained for the period which is longer

Retention of patient medical records

The retention period of various patient medical records is as under:

 Case records (Other than medico legal) 5 Years

 Case records with medico legal importance 15 years or till pendency of case
 Outpatient nominal register 2 years
 Casualty Register 3 years
 Night report and census register 10 years
 Operation and Anesthesia 10 years
 Mortuary register 15 Years
 Research files 15 years
 Transplant records 10 years and in microfilms thereafter

 Birth records Permanent

 Death Records Permanent
 Where there is chance of litigation arising out of negligence, retention for 25
years as minors have the right to sue the doctor in next 3 years after attaining
majority for negligence caused when he was minor
 Index Cards As for indoor files
 Admission and discharge registers Permanent
 Applications recd. From public/Govt. Officials for certificates etc. 3 years
 Anesthesia register 10 years

During whole retention period of records, the confidentiality and security is ensured. The
vital records i.e. ML Cases , death files are kept under separate Almirah with lock .

No original record will be issued except to the statutory authorities ( in which case a
photocopy is preserved before issuing) and policy is that if any one in the hospital wants to
see the records has to come to the section or only a photocopy will be issued

The records will be issued only when defined procedure duly authenticated by competent
authority of the hospital is followed
Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical records Section GH/MRD//NABH
Destruction of Patient Date 15/03/2019
Medical Records Revision No. 00

The destruction of medical records, data and information is in consonance with the laid
down procedure

Mode of Disposal :

By shredding /incineration to protect the confidentiality of patient in presence of a committee

constituted by the head of the institution

Procedure for disposal:

Files are pruned at the end of retention period once again to see any death/MLC file or any
other file which is required by any statutory authority which by mistake is mixed with these
files

A list is made mentioning patient name, age/sex, regd. No., date of admission, date of
discharge, name of consultant, diagnosis and any other special remarks

List submitted to competent authority/ medical records committee or its chairperson for
approval for disposal

The records so pruned will be shredded/ incinerated in presence of a committee constituted

by the competent authority who all will sign the document

The name of person handed over the shredded documents may also be recorded

Record preserved under lock and key

( Not to be advertised if there is no specific mandate from regulatory authorities)

 Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical Records Section GH/MRD/NABH
Date 15/03/2019
Revision No. 00

Quality Assurance:

 Pest Control measures

 Room free from dampness , fungus etc.
 No water seepages/ leakages
 Placement and knowing the use of fire extinguishers
 Caution against tampering of records/ Security
 Access Control
 Adhering to regulatory requirements
 Emphasizing on good quality of paper if integrity bad
 Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical Records Section GH/MRD/NABH
Date 15/03.2019
Revision No. 00

Date
Day
OFFICE MEMO

A committee with the following members has been constituted for overseeing the
disposal(shredding/incineration) of patient medical records after the retention period. It
would be the responsibility of in charge /technician medical records section to prune such
files and document the necessary details before seeking permission for final disposal

Mr. : in charge/technician medical records section

Mrs : Purchase and stores executive

Ms. : Receptionist

All the above members will sign the disposal record which will be kept under the custody of
in charge/technician of medical records section

Dr.

Medical Superintendent

Distribution: all above by name

For information: The Chairman

 Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical Records Section GH/MRD/NABH
Review of Medical Records Date 15/03/2019
Revision No. 00

Review of Medical Records

Statistical Principles for sample selection:

The probability methods are being used as the probability can be accurately measured

o Simple Random Sampling : Every file has a non zero probability of being selected
o Systematic Sampling;: Every Nth.file can be retrieved for review
o Stratified Sampling : Form subsets of population with at least 1 common
characteristic e.g. males and females and then can do random or systematic
sampling
Though the last one is more accurate, systematic sampling is chosen unless the population
is very small e.g. death cases in which all files can be monitored

Scope :

 All clinical departments and all type of cases e.g. death, LAMA, absconded , Discharges ,
discharge on request and referred cases

Procedure:

Done by medical records department and QM

Periodicity – Every 3 months

Sampling technique is adopted and conveyed to HoD of MRD for the sample size which is
usually 10% e.g. 10 files out of 100 discharged patients and every 10 th. file is taken for
review

Will record the findings in a structured format

Put up the findings / deficiencies to HoD for discussion in their respective departmental
meetings

Convey to Quality department/ Head of Institution the observations and CAPA

The same can be carried out for active patient records

HoD of MRD will also maintain a record of such reviews

 Gaba Hospital, Yamuna Manual of Operations Document No.
Nagar Medical Records Section GH/MRD/NABH
Date 15/03/2019
Revision No. 00

Review of Discharged Files

Name of Department/Unit Name ,Signature and designation of

Reviewer

Date/Month/Year

Audit Patient Patient Patient Patient Patient Patient

Attribute IP No. IP No. IP No. IP No. IP No. IP No.

General Consent

Financial Counselling

Reason for admission

Initial assessment timing

Completeness of initial
assessment

Dietary assessment

Nursing Assessment

Author of entry identified

Prescription dated, timed,

named, signed

Operative notes

Consents

Anaesthetists Notes

Pain assessment and

reassessment

Discharge summaries
completeness

Unapproved abbreviations

Final Diagnosis

Protocol for LAMA, Referral

Unique identifier on each
page

Uniform sprescription