CHAPTER 10.
INFORMATION
MANAGEMENT SYSTEM
(IMS)
National Accreditation Board for Hospitals and Health Care Providers
3rd Edition 4th Edition
Standard
IMS NUMBER OE Standard
IMS NUMBER OE
MEET THE INFORMATION MEET THE INFORMATION NEEDS
NEEDS OF ALL 1 5 OF ALL 1 5
EFFECTIVE MANAGEMENT OF
EFFECTIVE MANAGEMENT OF
DATA 2 5
DATA 2 6
ACCURATE MEDICAL RECORD 3 7
ACCURATE MEDICAL RECORD 3 8
CONTINUITY OF CARE 4 8 CONTINUITY OF CARE 4 8
MAINTAINING
MAINTAINING CONFIDENTIALITY,
CONFIDENTIALITY, INTEGRITY
INTEGRITY & SECURITY OF
& SECURITY OF INFORMATION 5 7
INFORMATION 5 7
RETENTION TIME OF
RECORDS, DATA & RETENTION TIME OF RECORDS,
INFORMATION 6 4 DATA & INFORMATION 6 4
REVIEW OF MEDICAL RECORDS 7 7 REVIEW OF MEDICAL RECORDS 7 7
TOTAL 7 43 TOTAL 7 45
National Accreditation Board for Hospitals and Health Care Providers
Section II:
Management Centered Standards
3rd 4th
edition edition
Information Management
7/43 7/45
System (IMS)
National Accreditation Board for Hospitals and Health Care Providers
Summary of Key Additions
Std/OE Detail Remarks
1 IMS 1 (a) The information needs of the organization are identified and Modified
are appropriate to the scope of the services being provided Interpretation
by the organization. to give better
‘Clarity’
Interpretation: The organization has manual and/or
electronic hospital information system and/or management
information system which provide relevant information to all
stakeholders concerned. The identified information needs
shall be documented. This shall include the information
needs of the care providers, management and external
agencies/governmental bodies. For example, daily census
report, utilization rates, etc.
There shall be a contingency plan in place to ensure
continuity in providing information needs when the
electronic hospital information system is experiencing a
downtime.
In case the organisation uses electronic medical records,
they could refer to EHR/EMR guidelines published by
MoHFW.
National Accreditation Board for Hospitals and Health Care Providers
Summary of Key Additions
Std/OE Detail Remarks
2 IMS 1 (d) Documented policies and procedures guide the use of New OE
Telemedicine facility in a safe and secure manner.
Interpretation: Whenever Telemedicine facility is used, the
organisation shall develop a ‘policy and procedure’ and
implement the same. This takes into account the patient’s
identity, confidentiality, limitations of Telemedicine and
other requirements (if any). The organisation shall have
mechanism for appropriate data storage and retrieval.
National Accreditation Board for Hospitals and Health Care Providers
Summary of Key Additions
Std/OE Detail Remarks
3 IMS 1 (e) The organization contributes to external databases in Modified
accordance with the law and regulations. Interpretation
to give better
Interpretation: The organisation shall define the system of ‘Clarity’
releasing the relevant information to the authority as per
statutory norms. For example, sending birth and death
statistics, notifiable diseases (refer to glossary) and acute
flaccid paralysis reporting. The organisation contributes to
databases in accordance national programmes and
initiatives for example – hemovigilance (HVPI) and
pharmacovigilance (PVPI).
National Accreditation Board for Hospitals and Health Care Providers
Summary of Key Additions
Std/OE Detail Remarks
4 IMS 2 The organisation has processes in place for effective For removing
control and management of data. ambiguity
5 IMS 2 (a) The organization has an effective process for document New OE
control.
Interpretation: The organization ensures that all
documents including forms, formats, policies and
procedures are current and updated. They are created,
reviewed for adequacy, authorized and released by
designated individuals. Only the latest authorized
documents are in use. Documents are reviewed for
updating them as per a planned schedule. All approved
documents are identifiable. Obsolete documents are
removed from use and archived as per a planned
retention period based on hospital’s policy. Filled in
forms, formats, etc. are retained as per the
organization’s policy and regulatory requirements.
National Accreditation Board for Hospitals and Health Care Providers
Summary of Key Additions
Std/OE Detail Remarks
6 IMS 3 (f) The organisation has a documented policy for usage of New OE
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.
7 IMS 4 (a) The medical record contains information regarding reasons Removed the
for admission, diagnosis and care plan. Words (ICD –
latest Edition)
Interpretation: The final diagnosis (IP) must be
to bring
documented by the treating doctor in all records. This
Uniformity.
could preferably be as per ICD. However, in the medical
records department all such diagnoses shall be codified as
per ICD. For definition of "Care plan" refer to glossary.
National Accreditation Board for Hospitals and Health Care Providers
Summary of Key Additions
Std/OE Detail Remarks
8 IMS 4 (c) Operative and other procedures performed are Modified to
incorporated in the medical record. give better
Interpretation: These include name and details of the ‘Clarity’
operative and other procedures performed.
9 IMS 4 (d) When patient is transferred to another hospital, the Modified
medical record contains the date of transfer, the reason Interpretation
for the transfer and the name of the receiving hospital. to give better
‘Clarity’
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.
National Accreditation Board for Hospitals and Health Care Providers
Summary of Key Additions
Std/OE Detail Remarks
10 IMS 4 (g) Whenever a clinical autopsy is carried out, the medical record Modified
contains a copy of the report of the same. Interpretation
remove
Interpretation: For definition of "clinical autopsy" refer to ‘Ambiguity’
the glossary. This does not include postmortems done for
medical legal cases.
11 IMS 6 (d) The destruction of medical records, data and information is
in accordance with the laid-down policy.
Interpretation: Destruction can be done after the retention
period is over and after taking approval of the concerned
authority (internal/external).
National Accreditation Board for Hospitals and Health Care Providers
Summary of Key DELETIONS
Std/OE Detail Remarks
(3rd
edition)
1 IMS 1 (c ) These policies and procedures are in compliance with Deleted
the prevailing laws and regulations. As implicit
coverage in
other Std/ OE
National Accreditation Board for Hospitals and Health Care Providers
Overall Impact of improvements: IMS
• Contingency plan in case hospitals IT system goes down
• Policies and procedures for telemedicine
• Document control policy
• Use of abbreviations
• In transfer cases, details are available in the medical record
National Accreditation Board for Hospitals and Health Care Providers
National Accreditation Board for Hospitals and Health Care Providers
