Medical Record Knowledge

  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 ...

The Medical Records Department (MRD) is essential to a hospital's operations, ensuring that patient information is accurately documented, securely stored, and readily accessible to authorized healthcare providers.  Its unique importance includes: 1. Accurate Documentation and Compliance:  The MRD ensures that all patient interactions and treatments are meticulously recorded, facilitating adherence to legal, regulatory, and accreditation standards. This comprehensive documentation supports quality care delivery and safeguards against potential legal issues.  2. Data Quality Management:  By overseeing the collection, storage, and analysis of health data, the MRD maintains high data quality standards. This involves ensuring accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, and timeliness of health information, which are vital for effective patient care and operational decision-making.  3. F...