Deficiency of Case Sheet

Chapter 10

Information Management System

(IMS)
IMS.3. The Organization Has A Complete And Accurate Medical Record For Every Patient.

Objective Elements
a. Every medical record has a unique identifier.
Interpretation: This shall also apply to records on digital media. Every sheet in the medical record shall have
this unique identifier. In case of electronic records, all entries for one unique identifier shall be available in
one place. For example, CR number, UHID, hospital number, etc.
b. Organization policy identifies those authorized to make entries in medical record.
Interpretation: Organization shall have a written policy authorizing who can make entries and the content
of entries. This could be different category of personnel for different entries, but it shall be uniform across the
organization, e.g. progress record by doctor and medication administration chart by nurse.
c. Entry in the medical record is named, signed, dated and timed.
Interpretation: All entries should be documented immediately but no later than one hour of completion of
the assessment/procedure. For records on electronic media it is preferable that the date and time is
automatically generated by the system.
d. The author of the entry can be identified.
Interpretation: This could be by writing the full name or by mentioning the employee code number, or
with the help of stamp, etc. In case of electronic based records, authorized e-signature provision as per
statutory requirements must be kept.

e. The contents of medical record are identified and documented. *
Interpretation: The organization identifies which documents form part of the medical records,
documents and implements the same. For example, admission orders, face sheet, IP sheet, discharge
summary, doctor's order sheet, TPR chart, consent form, etc.
f. The Organization Has A Documented Policy For Usage Of Abbreviations And Develops A List Based
On Accepted Practices.
Interpretation: In case abbreviations are used, a standardized list of approved abbreviations shall be
used throughout the organization. For medications, error prone abbreviations shall not be used.
g. The Record Provides A Complete, Up-to-date And Chronological Account Of Patient Care.
Interpretation: Every medical record has all the identified sheets filed in the proper order. The
organization shall decide the format for maintaining the continuity in the medical records. It shall
ensure that all medico-legal case records have the mandatory information. In case a particular sheet is
missing a note to that effect would be put in the medical record.
h. Provision Is Made For 24-hour Availability Of The Patient‘s Record To Healthcare Providers To
Ensure Continuity Of Care.
Interpretation: In case of physical records, when the MRD is not open, there should be a system in place
by which authorised personnel can open the MRD and retrieve the record. For all existing hospital
patients coming to the emergency room medical records shall be easily retrieved.
IMS.4. The Medical Record Reflects Continuity Of Care.
Objective Elements
a. The Medical Record Contains Information Regarding Reasons For Admission, Diagnosis And Care Plan.
Interpretation: The final diagnosis (IP) must be documented by the treating doctor in all records. This could
preferably be as per ICD. However, in the medical records department all such diagnoses shall be codified as per
ICD.
b. The Medical Record Contains The Results Of Tests Carried Out And The Care Provided.
Interpretation: It is preferable that the medical record also reflects any delay in tests and treatment planned or
provided for the patient. This could be taken up for clinical audit.
C. Operative And Other Procedures Performed Are Incorporated In The Medical Record.
Interpretation: These include name and details of the operative and other procedures performed.
d. When patient is transferred to another hospital, the medical record contains the date of transfer, the
reason for the transfer and the name of the receiving hospital.
Interpretation: It is mandatory to mention the clinical condition of the patient before transfer is effected. If the
patient has been transferred at his/her request, a note may be added to that effect. In such instances, the name of
the receiving hospital could be the name the patient desires to go to. However, if the patient has been transferred
by the organization, it shall document the same. All available details of the transfer are documented.
e. The Medical Record Contains A Copy Of The Discharge Summary Duly Signed By Appropriate
And Qualified Personnel.
Interpretation: Self-explanatory.
f. In Case Of Death, The Medical Record Contains A Copy Of The Cause Of Death Certificate.
Interpretation: This shall mention the cause, date and time of death The organization provides the death
certificate as per the International Form of Medical Certificate of Cause of Death (WHO). Cardiac and
respiratory arrest is an event of death and not the cause of death.

g. Whenever A Clinical Autopsy Is Carried Out, The Medical Record Contains A Copy Of The Report
Of The Same.
h. Care Providers Have Access To Current And Past Medical Record.
Interpretation: The organization provides access to medical records to designated healthcare providers
(those who are involved in the care of that patient). For electronic medical record system, identified care
providers shall have a user ID and a password.

Deficiencies Observed In
The Patient Case Files

Doctors Notes :
 Doctors Sign, Code Not Written In Some Sheets.
 Code Not Written Legibly.
Surgical Site Infection Prevention Bundle care form :
 Doctors sign and code not written.
Medication & Treatment chart :
 Doctors sign and code not written legibly

Discharge & death summary :
 Consultant code not legibly written in discharge
summaries.
Admission Record :
 Patient / Patient Attender’s sign & relationship not taken
during admission - Front office staff
OT Record :
 Duration of surgery (Starting & Ending time ) not written.
Doctor’s code not written.
Hemodialysis Record form :
 Doctor’s sign and code not written in some sheets.
Nursing initial assessment form :
 Some columns are found empty in few assessment forms.
Death forms & Death summary :
 Death forms (Form no.4) & death summary not written within 48
hours after death in some incidents.

LAB Requisition form :
 Complete the lab requisition form with sign & Code
 Do not use short forms
such as K+ , Ca, etc.

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Chapter 10

Information Management System

a. Every medical record has a unique identifier.

one place. For example, CR number, UHID, hospital number, etc.

b. Organization policy identifies those authorized to make entries in medical record.

automatically generated by the system.

d. The author of the entry can be identified.

statutory requirements must be kept.

summary, doctor's order sheet, TPR chart, consent form, etc.

missing a note to that effect would be put in the medical record.

Ensure Continuity Of Care.

And Qualified Personnel.

respiratory arrest is an event of death and not the cause of death.

h. Care Providers Have Access To Current And Past Medical Record.

providers shall have a user ID and a password.

The Patient Case Files

 Doctors Sign, Code Not Written In Some Sheets.

 Code Not Written Legibly.

Surgical Site Infection Prevention Bundle care form :

 Doctors sign and code not written.

Medication & Treatment chart :

 Doctors sign and code not written legibly

 Doctor’s sign and code not written in some sheets.

Nursing initial assessment form :

 Some columns are found empty in few assessment forms.

Death forms & Death summary :

hours after death in some incidents.

 Complete the lab requisition form with sign & Code

 Do not use short forms

such as K+ , Ca, etc.

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