MEDICAL RECORDS QUALITY INDICATORS

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. Speciality 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.
Admission
Admission of patient is one of the main process followed in any hospital. It is the first step in
providing healthcare to a patient as an in-patient. By admitting a patient, hospital undertakes
a high level of responsibility for the care and well-being of the patient and hence it is essential
to have relevant policy and procedure for admission in place to avoid any problems later on.
It also ensures that the patients are admitted uniformly irrespective of their ethnicity, religion,
caste, gender, financial class etc. This post describes relevant points that should be
considered while formulating a policy and procedure of admission. (Also read - Registration
of patient - Policy and Procedure)

Admission Policy
Right to admit a patient – Only those doctors (full time or on contract) who have been given
privileges of admitting the patient in the hospital can recommend patient for admission. This
is also applicable in case of patients from emergency. In case of patient being transferred from
another facility the admission shall be ordered by a doctor having admission privileges. An
updated list of such doctors shall be maintained at the admission department. Request for
admission by any other doctor or from directly from patient or family members or by any other
staff of the hospital shall not be considered.

Responsibility of care – The doctor who orders for admission shall be considered as the
primary doctor of the patient and he/she will be responsible for the medical care of the patient
till the discharge or transfer of patient to any other doctor. Hospital shall be responsible for
providing all facility and services necessary for patient’s stay and provision of medical care.

Information to patient – Every patient shall be provided with all the necessary information
before admission for him/her to make an appropriate decision. These information include
following
· Patients’ rights and responsibilities (A copy of patients’ rights shall be given)
· Type of accommodation available along-with its amenities and charges for the same
· Doctors round timing and how to contact doctors when required
· Provision of food, timing and whether or not food from outside is allowed
· Number of attendant who will be allowed to stay with the patient and arrangement for the
attendant
· Visitors timings and rules related to visiting patients
· Keeping of valuables in the hospital
· Payment timings and mode of payments (In case of insurance patient details related to
insurance payments)
· Code of conduct during stay

Cost estimate – Each patient at the time of admission shall be provided with an estimate of
total cost of treatment. This shall be estimated with the help of the admitting doctor and by
referring to the schedule of charges. The cost estimate shall be given to the patient in written.
A disclaimer shall be made that the estimate may vary by certain percentage and may change
significantly in case there is a change in treatment plan. In such cases a revised estimate will
be given to the patient.

General consent – A written general consent shall be obtained from each patient upon
admission. This shall be as per the general consent policy. Standard general consent
form shall be used for obtaining the consent.

Non-availability of beds – In case the bed is not available in the category chosen by the
patient the policy on ‘managing during non-availability of beds’ shall be followed
Identification of patient - Appropriate Idnetification mechanism of the patient shall be created
as per patient identification policy In case of an un-identified patient (for eg. Patient is sub-
conscious or mentally unstable) admission shall be done by generating a temporary
identification details. This shall be corrected as soon as identity gets established.

Behaviour with patient – During the entire admission process the admitting staff shall be
courteous, helpful and maintain good behaviour towards the patient. Patient shall be given
sufficient opportunity to ask questions and clarify doubts. Rude behaviour or neglect of patient
shall not be tolerated and can lead to penal action.

Privacy and confidentiality – The communication between patient and admitting staff shall
be carried out with sufficient privacy. All information collected from patient shall be kept
confidential.

Non-discrimination – The admission policy and process shall be uniformly applied to all
patient seeking admission. No discrimination shall be done on the basis of patient’s ethnicity,
religion, caste, gender, financial class and any other background of the patient.

Admission Procedure
· Admission process of a patient shall be carried out at the admission desk/admission
chamber. The process starts as soon as the patient arrives to the desk with the admission
order from the doctor.

· Check the written admission order brought by the patient and ensure that it is from a
doctor who has the admission privileges granted by the hospital. In case, patient do not have
the appropriate written order, admission shall not be done and patient shall be appropriately
guided.

· Obtain necessary details of the patient. This can be done through the Unique ID number
of the patient which was generated during registration. Additional details shall be obtained
by asking the patient to fill up the admission form. In case of unidentified patient a temporary
identification shall be provided for the purpose of completing admission.

· Allocation of bed/room – Inform the patient about various categories of accommodation

available, its features and cost. Help the patient in selecting an appropriate accommodation
of his/her choice. In case the chosen category is not available, follow the policy and procedure
of ‘Managing during non-availability of beds’

· Information provision – Provide all information to the patient as described in the policy
above. Patient information booklet that contains all necessary information, along
with patients’ rights shall be handed over to the patient

· Cost estimate provision – The admission staff in consultation to the doctor should work out
an estimate of the total cost that would be incurred to the patient. This cost estimate shall be
given to the patient in written. A copy of this estimate, duly signed by the patient shall be
retained as an evidence.

· Taking general consent – General consent shall be taken from the patient after provision
of information and cost estimate and after final confirmation of admission. This should be done
as per general consent policy and in the standardized format

· Registering the admission– Patient’s admission shall be registered/recorded in the system

as per the patient’s choice of accommodation and availability of beds.
· Generation of Patient identifier - Patient identifier shall be generated which includes
Patient ID band and patient's identification labels (sheet of stickers with printed patient
identification details) shall be generated. This shall be as per patient identification policy
and procedure.

· Generation of medical record – A medical record shall be generated for the patient which
should have patient details and basic formats within it. If the patient is an existing patient, who
has been admitted in past, the previous medical record number shall be stated on the new
medical record file created.

· Payment of advance – Patient/family member shall be asked to pay the required advance
amount at the billing counter and submit the receipt back.

· Sending patient to ward - After successful payment, patient shall be directed towards the
appropriate ward. An attendant should to escort the patient, if needed. The medical record
and patient identifier (ID band and the identification labels) shall also be sent to the ward by
the hands of attendant.

· Internal communication – Immediately after admission information shall be sent to the ward
in-charge and to the accounts department

· In the ward – The ward in-charge upon receiving the information shall allocate a primary
nurse for the patient. As soon as the patient arrives, primary nurse shall help the patient to get
into the room/bed. She should then make an entry in the ward’s admission/discharge register
and sends an information of new admission to the medical officer on duty and the admitting
doctor.

· In case of any unforeseen event the Hospital Administrator shall be contacted who will take
appropriate decision as per situation.
Code red is an emergency code which is used to alert employee and fire-fighting team in case
a fire or possibility of fire is detected within the hospital premise. Unexpected fire is considered
as an emergency situation and code red system is used to urgently activate a set of action
intended to control the fire and prevent any major mishap. The system may slightly vary from
hospital to hospital, depending upon how the hospital is structured and organized. Here is a
code red system that can be used as a reference by hospitals. (Other codes - Code
Blue, Code Pink)

CODE RED POLICY

‘Code Red’ is used as a code word to alert employee and fire-fighting team on un-expected
detection of fire or possibility of fire anywhere within hospital’s premise. All employees are
expected to know the ‘Code Red’ system and must adhere to the action plan and guidelines
to be followed under this system. The intercom line with number 1111 is dedicated for calling
and activating code red. This number can be called from any intercom device and should be
used only in the event of fire.
Employees are also expected to know the location of the nearby fire-extinguisher and
emergency exit route to be used for the area where they work. A new employee in the hospital
must be oriented to the code red system on first day of the work. Following system shall be
used for Code Red.
 CODE RED ALERT ACTIVATION
Code red shall be activated by any employee of the hospital who detects or is informed about
unexpected fire flames, smoke, smell of smoke, unusual heat or any other indication of fire.
The fire or fire like situation could be observed in any part of the hospital, including hospital’s
exteriors and terrace. Code red should be activated even if it is uncertain, if the situation is
caused because of fire or not.
For activating code red the intercom number ‘1111’ should be called from the nearest intercom
device and ‘Code Red’ followed by the location details shall be spoken. For example, if the
fire is observed in the hospital’s main kitchen, the employee should call 1111 and say, ‘Code
Red alert – Hospital’s main kitchen’. This should be repeated thrice in clear voice so that the
receiver at the other end understand the code and location.
The intercom line ‘1111’ is manned by a telephone operator round the clock, who has access
to public announcement system. As soon as code red alert call is received, he/she immediately
uses public announcement system to announce ‘May I have your attention please. Code Red
at ….. area’. This activates code red system in hospital. The announcement shall be repeated
3 times initially in clear voice and then shall be repeated intermittently after that.

ACTION PLAN FOLLOWING CODE RED ALERT

As soon as code red alert is announced, employee should follow the action plan as described
below

Employee near to the area where fire is detected – As soon as code red is announced, all
employee who are near the location where fire is detected, should immediately assess the
severity of fire and follow R.A.C.E

 Rescue all patients, visitors and staff from immediate danger

 Alarm others in the nearby area and call for help

 Confine the fire in the area by closing doors and windows

 Extinguish the fire if the fire is small, by using fire extinguisher. Fire extinguisher should
be

 used as per P.A.S.S. protocol, which is

o Pull the pin of fire extinguisher

o Aim the stream at the base of the fire

o Squeeze the lever slowly and gently

o Sweep from side to side

Employee near the fire area must also

 Keep themselves safe from fire

 Wait for direction from hospital’s authority or fire-fighting team in-charge for any further
actions

 The doctor or head nurse of the area must decide, if the central oxygen supply of their
area, shall be shut. The valve of oxygen supply can used for this purpose or the technician
from maintenance department can be asked for this

 Shut all the fire doors in nearby areas to prevent spread of smoke. These doors shall
only be used for passing through them

Hospital administrator – He/she will immediately reach the place and taking care of his/her
own safety, assess the situation. He/she shall ensure that R.A.C.E protocol is initiated and
shall also take decision on whether patients and others needs to be evacuated and whether
to call fire brigade immediately, without waiting for hospital’s fire-fighting team to arrive. Any
situational decisions shall be taken by him/her till the time of reaching of fire-fighting team after
which the situation shall be handed over to them.
In absence of hospital administrator the in-charge of the area where fire is detected shall
perform these functions.

Employees who are away from the fire location – All other employee shall must note the
location where fire has been announced and shall do following

 Do not go towards the area where fire has been detected, unless and until specifically
called upon or required

 Listen for additional instructions and be ready to help in case required

 Prevent and other outsiders in their vicinity from going towards the fire affected area

 Keep all fire doors closed except while passing through them, to prevent spread of fire
and smoke

 Be ready to evacuate if directed

 Do Not use elevators

In-charge of Central oxygen supply: He/she shall wait for instruction on whether Oxygen
supply shall be closed to the area where fire is detected and do according to the instruction.
He/she shall be available for any further instruction

Fire-fighting team – The fire-fighting team is composed of 4 personnel from security and
maintenance. The members of fire-fighting team are trained on fire-fighting measures. Three
 teams are constituted and it is ensured that one team is present in all shift. There is an in-
charge of each team. The firefighting team must do following on listening code red alert

 Reach to the place where fire has occurred on an urgent basis

 Take charge of fire-fighting measures from the employees on sight

 Pass on necessary instructions to the people present over there for safety

 Start controlling the fire as per the training given to them

Fire-fighting team in-charge: The in-charge should also reach the place along with other
team members. The in-charge will lead the fire-fighting team and will also do following

 Assess the situation and determine, if the fire is severe enough to call for external help

 Decide whether evacuation plan needs to be initiated

 Decide whether Fire Brigade needs to be called

 Any other decision that needs to be taken

Fire Brigade – In case fire brigade is called, the fire-fighting team should continue their effort
till the time it reaches. Focus should be on safety. As soon as the fire brigade arrives, the
situation should be handed over to them and their direction should be followed

Evacuation – In case evacuation needs to be done, hospital’s evacuation plan for each area
shall be followed. This should be supervised by the fire-fighting team.

CODE RED – ALL CLEAR

The fire-fighting team in-charge has the authority to declare if the situation has been tackled
and is safe from fire. For this the in-charge calls back ‘1111’ and says ‘Code Red – All Clear’.
On getting this information, the operator then announces the same on public announcement
system. Employee on listening ‘Code Red – All Clear’ can assume that the fire emergency
has been taken care of and they can resume back to their normal work.
The employees, patient and visitors of the area where fire occurred shall be instructed, if the
area can be used or not. Also, any patient or employee if injured during the incident shall
immediately be taken to hospital’s emergency for treatment.

DOCUMENTATION
Code red event whenever occurred (real or mock) must be documented to keep a record and
for further improvement. This shall be done by preparing a report within 3 days of occurrence
of the incident. The report shall be prepared by the in-charge of fire-fighting team in
consultation with the employee of area where fire was detected. The report must contain
following points and shall be submitted to CEO
 Date and time of code red activation

 Severity of fire

 Measures taken for controlling fire (both by employee and team)

 Whether fire brigade was called?

 Whether evacuation was done?

 Losses – injuries, death, damage of property etc.

 Probable causes of fire

 Problems identified and corrective actions to be taken