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Benchmarking Medical Records Department in Accordance with NABH Standards

  • Priyanka Singh
  • Agency : Medical Records Department, NABH Standards
  • Objective : This study analysis the current situation and quality of medical records before the pre-assessment of the organization. The purpose of the study was to find whether the organization was ready for the upcoming accreditation and if not then assess the gap and fill them.
  • Background : The medical record section of a hospital serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient's care, assisting in protecting the legal interest of the patient and the health care providers responsible for the patient's care, and documenting the care and services provided to the patient
  • Methodology : The standards of the IMS were assessed in a self assessment toolkit whereby most of the objective elements were found to be ZERO in scoring. Therefore new policies & procedures were formulated and implemented and then reassessed. Data was collected by one to one discussion with the staff from the MRD, nursing, and few consultants & previous record and observation primarily and NABH manual of other hospital, literature on internet secondarily
  • Findings : The retrieval of a file in MRD was found to be 22 minutes and this by following the new policy decreased upto 11%. The completeness of the medical records is very important because as also it reflects the standard for IMS in continuity of care as per the guideline of NABH, but this was found to be in very poor shape i.e. only 18% files were found to be completed by the nursing staff. Similarly even the doctors (mainly the consultants under which the patients was admitted) showed a very poor data as only 28% files were found to be complete (i.e. 72% incomplete in terms of doctors sign & stamp, daily notes and updates in the treatment). This data after following the new policy went upto 78% in the nursing staff and only 68% by the doctors for the completion of the records. The medical records must reach the department after 1 day of the discharge but only 16% of the files reached around 84% reached the department in around 48 hours. This data increased from 16 % to 78% after the new policy.
  • Recommendations : As for the scope of study in future, it can be used as a literature on benchmarking of medical records & thus be received as in similar research studies. The major limitation that existed was majorly of the shortage of the qualified & skilled staff as the entire MRD of a 200 bedded hospital was handled by only 2 people out of which one was not at all qualified.
To analysis the current situation and quality of medical records before the pre-assessment of the organization