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Adityavardhan Hospital: Policies & Procedures

Adityavardhan Hospital in Thane, Maharashtra has documented procedures for retaining medical records, data, and information. The procedures specify retention periods of 5 years for outpatient records, 7 years for inpatient records, and lifelong retention for medico-legal case records. Medical records are reviewed monthly to ensure timely, legible, and complete documentation. Any deficiencies found during review are analyzed, and corrective and preventive actions are implemented.

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Sanjay Kadam
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400 views

Adityavardhan Hospital: Policies & Procedures

Adityavardhan Hospital in Thane, Maharashtra has documented procedures for retaining medical records, data, and information. The procedures specify retention periods of 5 years for outpatient records, 7 years for inpatient records, and lifelong retention for medico-legal case records. Medical records are reviewed monthly to ensure timely, legible, and complete documentation. Any deficiencies found during review are analyzed, and corrective and preventive actions are implemented.

Uploaded by

Sanjay Kadam
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ADITYAVARDHAN HOSPITAL

SADICHHA TOWER, LBS MARG, THANE – W, MAHARASTRA.

Documented procedures exist for retention time of


medical records, data and information.

Policies & Procedures


Doc No AH /NABH / POL / 14
Adityavardhan Hospital Issue No 01
Documented procedures exist for Rev. No 00
retention time of medical records, data Date of Approved 01/12/2019
and information. Page Page 2 of 4

DOCUMENT CONTROL :
Document Name : Documented procedures exist for retention time of medical records,
data and information.
Document No. : AH/NABH / POL/ 14

Prepared By: Quality Team DOC No: AH/NABH/POL/14 Approved By: MEDICAL DIRECTOR
Doc No AH /NABH / POL / 14
Adityavardhan Hospital Issue No 01
Documented procedures exist for Rev. No 00
retention time of medical records, data Date of Approved 01/12/2019
and information. Page Page 3 of 4

CONTROL OF THE MANUAL

The holder of the copy of this manual is responsible for maintaining it in good and safe
condition and in a readily identifiable and retrievable.

The holder of the copy of this Manual shall maintain it in current status by inserting latest
amendments as and when the amended versions are received.

Management Representative is responsible for issuing the amended copies to the


copyholders, the copyholder should acknowledge the same and he /she should return the
obsolete copies to the Management Representative.

The amendment sheet, to be updated (as and when amendments received) and referred for
details of amendments issued.

The manual is reviewed once a year and is updated as relevant to the hospital policies and
procedures. Review and amendment can happen also as corrective actions to the non-
conformities raised during the self-assessment or assessment audits by NABH.

The authority over control of this manual is as follows:

Preparation & Approved Issued Implemented

Admin Medical Director NABH coordinator /Admin/HR

The procedure manual with original signatures of the above on the title page is considered as ‘Master
Copy’, and the photocopies of the master copy for the distribution are considered as ‘Controlled
Copy’.

Distribution List of the Manual:

S.No. Designation
1 Medical Director
2 Admin
3 Accreditation Coordinator /Admin/HR

Prepared By: Quality Team DOC No: AH/NABH/POL/14 Approved By: MEDICAL DIRECTOR
Doc No AH /NABH / POL / 14
Adityavardhan Hospital Issue No 01
Documented procedures exist for Rev. No 00
retention time of medical records, data Date of Approved 01/12/2019
and information. Page Page 4 of 4

Documented procedures exist for retention time of medical records,


data and information.

1. Retention time of records, data and information:


1.1 Retention period of records: The entire Outpatient case sheets shall be maintained for a
period of 5 years after the last visit made by the patient. All the Inpatient case sheets
shall be maintained for a period of 7 years after the last visit made by the patient. The
MLC case sheets shall be retained lifelong or till the final judgment from the Supreme
Court. The records which have crossed the retention period shall be selected and
destroyed as per documented procedure.
1.2 Review: Medical records shall be reviewed once in a month. Review shall be done taking
samples as per statistical table depending upon the population (No. of files generated
during the month). The selection of samples shall contain both active and discharged
patients. The review shall be done by Quality coordinators for the timeliness, legibility
and completeness of the medical records in the IP Op patient files. Deficiencies: A
report shall be prepared for the deficiencies observed during review process; the
observed deficiencies shall be analyzed for the root cause and corrective action and
preventive action shall be identified; the corrective and preventive action shall include
if necessary to check entire population of files of the month to regularize the records.

Prepared By: Quality Team DOC No: AH/NABH/POL/14 Approved By: MEDICAL DIRECTOR

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