MRD Guidline NABH

MEDICAL RECORD CHECKLIST

MRD guideline NABH

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)
S.NO ACTIVITY YES/NO
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)
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 Medication orders and charts should not have any non-standard

abbreviations. Or should have only those abbreviations that are
defined by the hospital
15 Entries in medical records should be up-to-date
16 Medical records of Patients who have undergone surgery should contain
following documentation
Pre-operative assessment
Type of anesthesia and anesthetic medications used
Safety checklist to prevent surgical errors (like WHO surgical safety
checklist)
Informed consent (refer point no. 11 also)
Operative note by the surgeon or his/her team member
Post-operative plan of care
17 Informed consent in medical records should contain following:

1. Information on the surgical procedure, risks, benefits,
alternatives, name of the doctor who will perform surgery
2. Informed consent should be in language that patient understand
(having a bi-lingual consent form can be of help)
3. Consent form signed by patient (or guardian if applicable)
4. Consent form signed by the doctor taking consent
5. Consent form signed by an independent witness.
17 Medical records of discharge patients should contain following

documents
1. Discharge summary (refer point no. 14 also)
2. Death summary in case of deaths (should mention
cause of death)
3. Final diagnosis of the patient
4. ICD coding on the file within a defined timeframe
5. In case of autopsy, a copy of autopsy report
18 Discharge summary of patient should contain following

documentation
1. Patient’s name, demographic details and unique identification
number
2. Date of admission and date of discharge
3. Reason of admission, significant findings, diagnosis and patient’s
condition as the time of discharge
4. Information regarding investigation results, any procedure
performed, medication administered and other treatment given
5. Follow up advice, medication and other instructions
6. Instruction on when to obtain urgent care

7. Instruction on how to obtain urgent care.
19 Safety, security and confidentiality of medical records. Medical

records department should additionally take care of following points,
1. Sufficient and safe storage for medical records
2. Regular pest control in medical record storage area
3. Availability of fire extinguisher near-by and knowledge on
how to use the same
4. Policy of who can access medical records
5. How to respond to different request for accessing medical
records
6. Mechanism to quickly retrieve the medical records
7. ICD codification
8. 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 medical records in which nursing care plan is documented
4 Percentage of medication chart with error prone abbreviations
5 Percentage of medical records not having ICD codes
6 Percentage of medical records not having discharge summary
7 Percentage of medical records having incomplete/improper consent
8 Percentage of missing document

MRD Guidline NABH

Uploaded by

Copyright:

Available Formats

MRD Guidline NABH

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

MRD Guidline NABH

Uploaded by

Copyright:

Available Formats

MEDICAL RECORD CHECKLIST

MRD guideline NABH

3 If applicable, MLC identification and number and details should be

4 Medical record should contain general consent of the patient in

5 Medical records of currently admitted patients must contain

6 Initial assessment record should have name, signature, date and

9 If patient is transferred to other hospital, medical records should

10 Each entry in medical records should be signed, named, dated and

11 Entries in medical records should be legible

13 Entries in medical records should be up-to-date

14 Medication orders and charts should not have any non-standard

17 Informed consent in medical records should contain following:

17 Medical records of discharge patients should contain following

18 Discharge summary of patient should contain following

6. Instruction on when to obtain urgent care

19 Safety, security and confidentiality of medical records. Medical

Quality Indicators Medical Records:

You might also like