What is the MRD Indiator

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 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 colour 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-colour coding: Green = Achieved, Yellow = Warning, Red = Action Needed) + monthly graph?  






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