What is the MRD Indiator

 NABH Standards Applicable to Medical Record Department (5th Edition) 

Below Medical Record Indicator

| NABH Standard | Key Requirement | Target / Compliance Level | Evidence / Documentation Required 

| AAC.11 | Timely completion of medical record completion | 100% | All inpatient records must be completed within **72 hours** of discharge. Deficiency register, daily monitoring sheet, correction log 

| AAC.12 | Uniformity and completeness of clinical records | 100% | Standardized format containing history, examination, consents, progress notes, investigation reports, operation notes, anaesthesia records, discharge summary, ICD codes |

| AAC.13 | Issuance of Discharge Summary at the time of discharge | 100% | Discharge summary handed over to patient/attendant before leaving the hospital. Acknowledgement register mandatory |

| AAC.14 | International Classification of Diseases (ICD-10) and Procedure Coding (ICPT) | 100% | Every final diagnosis and procedure must be coded as per latest ICD-10 & ICPT. Coding register + competency certificate of staff |

| AAC.15 | Proper identification and documentation of Medico-Legal Cases | | 100% | Separate MLC register, police intimation copy, injury certificate, red label/sticker on file, proper consent for procedures |

| AAC.16 | Record retention and destruction policy | Documented policy | OPD records – 5 years<br>IPD records – 10 years<br>Medico-legal records – 30 years or till final disposal of case<br>Destruction only by authorized committee with proper documentation |

| AAC.17 | Security and confidentiality of medical records | 100% compliance | Fire-resistant cabinets, restricted access (lock & key/biometric), CCTV coverage, confidentiality agreement signed by all MRD staff, incident reporting mechanism |

| AAC.18 | Retrieval of medical records | Within 15–30 minutes | Tracer card / barcode / software-based tracking system, issue-receipt register |

| PRE.4 | Registration of Births and Deaths | 100% within 72 hours | Online entry in CRS portal, maintenance of statutory forms (Form 1, 2, 4, 5) and registers |

| IMS.2 | Periodic medical record audit/review | Minimum 10 records/month | Monthly internal audit of randomly selected files, deficiency identification, corrective & preventive actions, re-audit evidence |

 Key Registers Mandated by NABH for MRD

1. Medical Record Deficiency Register  

2. Record Completion & Correction Register  

3. ICD-10 & ICPT Coding Register  

4. Medico-Legal Case Register  

5. Birth & Death Registration Register  

6. Record Issue & Receipt Register  

7. Record Destruction Register  

8. Monthly Medical Record Audit Register  

Minimum Staffing Requirement (as per NABH 5th Edition – District/Sub-District Hospital)

- Medical Record Officer (MRO) – 01 (preferably Graduate/PG in Medical Record Science)  

- Medical Record Clerk / Data Entry Operator – 1–2  

- Record Arranger / Attendant – 1–2  

Critical Observation Areas During NABH Assessment (Tracer Activity)

- Random selection of 8–10 discharged patient files for completeness, timeliness, coding accuracy, and consent documentation  

- Verification of ICD coding accuracy (acceptable error rate ≤2%)  

- Physical inspection of record storage area (fire safety, access control, CCTV)  

- Staff interviews regarding confidentiality and retrieval process  

This document is fully aligned with NABH 5th Edition standards (April 2020 with subsequent amendments up to 2025) and is written in formal professional language acceptable for accreditation files.

MRD – Key Performance Indicators Dashboard 2025  

(Super Attractive Wall-Chart / Monthly Report Format – 

| Sr. | Indicator (What decides your monthly report card) | Calculation Formula | Target (Must Achieve) | This Month’s Score | Status |

| 1 | Inpatient Records Completed within 72 Hours of Discharge | (Records completed in 72 hrs ÷ Total discharges) × 100 | 100% 

| 2 | Discharge Summary Handed Over at the Time of Discharge | (Patients given summary ÷ Total discharges) × 100 | 100% 

| 3 | ICD-10 & ICPT Coding Done in 100% IPD Files | (Coded files ÷ Total IPD files) × 100 | 100%

| 4 | Birth & Death Registered on CRS Portal within 72 Hours | (Events registered in 72 hrs ÷ Total events) × 100 | 100%

| 5 | Medico-Legal Cases – Full Documentation + Police Intimation | (Complete MLCs ÷ Total declared MLCs) × 100 | 100%

| 6 | Average Time to Retrieve an Old Record | Average time taken for all requests | ≤ 30 minutes

| 7 | Record Perfectness in Monthly Audit (10 random files) | (Perfect files ÷ 10 audited files) × 100 | 95–100%

| 8 | ABHA ID Created / Linked at Discharge | (Patients with ABHA ÷ Total discharges) × 100 | 95–100%

 Example – How it looks when filled (November 2025)

| Sr. | Indicator | This Month | Target | Status |

| 1 | 72-Hour Record Completion | 99.8% | 100% | Excellent |

| 2 | Discharge Summary at Discharge | 100% | 100% | Excellent |

| 3 | ICD-10 Coding Compliance | 100% | 100% | Excellent |

| 4 | CRS Registration within 72 hrs | 100% | 100% | Excellent |

| 5 | MLC Documentation & Intimation | 100% | 100% | Excellent |

| 6 | Average Retrieval Time | 17 min | ≤ 30 min | Excellent |

| 7 | Monthly Audit – Perfect Files | 100% | 95–100% | Excellent |

| 8 | ABHA ID Creation/Linkage | 98.5% | 95–100% | Excellent |

Print this on A3 color paper → laminate → hang in MRD room.  

Everyone (MS, NABH assessors, staff) will instantly see how well MRD is performing!

Want this exact table in **Excel format** (with auto-color coding: Green = Achieved, Yellow = Warning, Red = Action Needed) + monthly graph?  

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