LINEN MANAGEMENT

1
• HIC 1e : Laundry and linen
management practices are also
included.

2
 Documentation of linen and laundry management
in the HIC manual.
Daily washing records.

Staff training records on linen management.

Evidences PPE usage by staff handling wet and dry linen.

SDS for all chemicals used.

MOU – if outsourced.

3
KITCHEN SANITATION AND
FOOD HANDLING

4
ENGINEERING CONTROLS TO PREVENT INFECTIONS

5
Basic Requirements for Environmental Controls

Basic requirements of
environmental controls include:
• Water management.
• Theatre environment.
• Protective environment rooms.
• Facility management.

6
Testing Drinking Water

Physical testing of drinking water Chemical testing of water should be Biological testing should be done
should be done daily, which includes done by an accredited facility once in every month (By the microbiology
colour, odour and taste. 6 months. department inhouse or outsourced).

To ensure that the sewage from the

hospital is treated appropriately and
The alternate sources of water like does not pose any danger to the
bore-well, tanker water, well water community, the physical quality of
etc. which are kept as a backup in the treated water should be checked
case of water shortage should also be daily. The chemical quality of the
checked once in six months. treated water should be done once in
six months and the biological quality
should be checked monthly.

7
Testing Sewage Treatment

Sewage
treatment (Limits
as per PCB):

Chemical quality:
Physical quality: Biological quality:
Once in 6
Daily. Monthly.
months.

8
 Water Analysis

For an entry level, the best practice for analysing drinking water is once in a month.

Checking the residual chlorine levels of the RO water for dialysis should be done after
the weekly cleaning at the terminal ends before connecting to the machine.

Endotoxin levels for the RO water for dialysis should be done once in a month.

Scrub water should be checked once a week.

9
 Theatre environment should have the zoning done appropriately.

Entry should be restricted.

Patients should not be brought beyond the red line in theatre. And,
transfer trolleys should be used.

Theatre Theatre staff should wear proper attire.

Environment Operation theatre (OT) walls and floor should be free of crevices and
cracks.

The floor should be seamless with curved edges. This would prevent
accumulation of dirt and micro-organism and would be easy to clean.

Cleaning records should be maintained.

10
AC in It is mandatory for full NABH accreditation to
have the following in each OT:

Theatre • Individual air handling unit (AHU) for each

theatre.
• Laminar flow and high efficiency particulate air
(HEPA) filters in case of ultra clean theatres.
• Air changes, positive pressure, relative
humidity and temperature should be
monitored and documented daily.

The air-conditioning system should not be

switched off and should be maintained with a
variable frequency devices (VFD) and a blower to
prevent spore formation in the ducts.

11
Filter Cleaning
▪ The integrity of the filters and the system should be checked every six
months.
▪ HEPA should be changed if the particle count is high.
▪ The pre-filters at the AHU should be washed every week and maintained
appropriately.
▪ Records of checking should be maintained.

Note: For entry level certification, split AC system and window AC

are permitted in theatres. The filters of the window AC should be
cleaned weekly and unit should be maintained weekly. And, the
process should be documented.

12
Protective • Protective environment rooms like burns
unit, transplant units and isolation units
Environment should be planned and constructed as per
the norms
Rooms • Air-conditioning requirements like positive
pressure in case of transplant or burns
unit and negative pressure in case of
isolation units should be provided.

13
Isolation Requirements
• If isolation units are not available in the hospital and
patients with air-borne infections are admitted, then to
prevent the spread of infections:
▪ Each patient should be placed in single/private rooms with
closed doors.
▪ Patients with same illness can be placed in same room.
▪ There should be no central AC supply in any rooms.
▪ Each room should have separate AC unit
(window/split/non-AC room).

14
Isolation Requirements in a
Block with Central AC
▪ The door should be kept shut.
▪ Windows should be open.
▪ Inlet and outlet AC duct should be blocked.
▪ Powerful exhaust for airflow (from outside to inside the
room, in and out through window and when the door is
opened) should be available.

15
INFECTION CONTROL GUIDELINES FOR THE MORTUARY

16
 Requirements

17
▪ A separate area should be
designated as mortuary and should
be under lock and key with strict
access control.
▪ The facility should be clean.
▪ It should have a cold storage with
temperature monitoring and power
back up.
HIC 3 : Biomedical waste (BMW) management practices are followed.

18
• Any waste that is
generated during
diagnosis, treatment or
immunisation in
hospitals, laboratories
and blood bank is called
a biomedical waste.

19
• HIC 3a: The hospital is authorised by
prescribed authority for the management
and handling of biomedical waste.

20
 • The health care organisation must possess a
NOC from State Pollution Control Board
Statutory (PCB) for generating, storage and disposal of
BMW.
Requirement

21
 • The guidelines and code of practice for
managing BMW are uniform for:
▪ Hospitals, nursing homes, clinics and
Uniformity in dispensaries.
Guidelines ▪ Veterinary institutions and animal houses.
▪ Pathological laboratories and blood banks.
and Code of ▪ Ayush hospitals and clinical establishments.
▪ Research or educational institutions.
Practice ▪ Health camps, medical or surgical camps,
for Managing vaccination camps and blood donation
camps.
BMW ▪ First aid rooms of a school.
▪ Forensic laboratories and research labs.

22
 • Remember that the BMW rules of 2016 do not apply to:
▪ Radioactive Wastes, Atomic Energy Act, 1987
▪ Hazardous Chemicals Rules, 1989
▪ Solid Wastes covered under MSW, Rules, 2000
▪ Lead acid batteries, Batteries Rules, 2001
▪ Hazardous Waste management Handling &
Transboundary Movement Rules, 2008
▪ E-waste, E-waste Rules, 2011

BMW Rules ▪ Hazardous microorganisms Rules, 1989

23
 • The evidences that establish that the
hospital has followed HIC 3a NABH standard
are:
1. Authorisation for generating BMW.
Evidences 2. Outsourced vendor license for collecting
waste.
3. MOU.

24
HIC 3b: Proper segregation and collection of
biomedical waste from all patient-care areas of the
hospital is implemented and monitored.

25
Segregation of BMW – Colour Coding

26
1%

27
28
29
30
 GREEN CATEGORY
80% are general waste
▪ Office paper
▪ Food items
▪ Wrappings and covers
▪ Covers of medical equipment

31
 • Day............ Month..............
Year...........
• Date of generation ................... Waste category
Number........ Waste quantity…………
• Sender's Name and Address:
Receiver's Name and Address:
Before
Transportation : • Phone Number ........
Points to Phone Number ...............
• Fax Number...............
Remember Fax Number .................
• Contact Person ........
Contact Person .........
• In case of emergency please contact :
• Name and Address :
• Phone No.

32
 ▪ The occupier of all bedded health care units, shall
maintain and update on a day to day basis the bio-
medical waste management register.

▪ All bedded healthcare units shall display the monthly

BMW record of waste disposal management on its website.

Management
▪ Such health care facilities (irrespective of any number of
(Amendment) beds), shall make the Annual Report available on its
web-site before 19 March 2021.
Rule - 2019
▪ Health care facilities having less than ten beds shall
have to comply with the output discharge standard for
liquid waste by 31st December 2019.

33
Monitoring
Biomedical
Waste
Management
Audit Form

34
35
 The evidences that establish that the hospital has
followed HIC 3b NABH standard are:

1.Documentation of BMW - practices HIC

manual.

Evidences 2.Appropriate colour coded bins.

3.Posters of BMW segregation.
4.Staff training records.
5.Audits on waste segregation practices.

36
HIC 3c: Biomedical waste treatment
facility is managed as per statutory
provisions (if in-house) or
outsourced to authorised
contractor(s).

37
 • The treatment facility where BMW is finally
treated before disposal should be authorised
Statutory by the State Pollution Control Board.
Requirement

38
 The evidences that establish that the hospital
has followed HIC 3c NABH standard are:
1.License to operate – updated.
Evidences 2.Site visit records.

39
HIC 3d : Requisite fees, documents and
reports are submitted to competent
authorities on stipulated dates.

40
 • The hospital should submit the
following forms 1-5:
1.Accident reporting
2.Application for
authorisation/renewal
Forms 1-5 3.Authorisation
4.Annual report
5.Application for filing appeal

41
 • Hospital should report the
following incident:
▪ Fire hazards or blasts.
▪ Toppling of the truck carrying
BMW.
Incidents to be ▪ Accidental release of BMW in
any water body.
Reported • Note: The hospital doesn’t have
to report accidents like
needlestick injuries and mercury
spill.

42
 The evidences that establish that
the hospital has followed HIC 3d
NABH standard are:
1. Forms
2. Records of waste generated
Evidences 3. Monthly updation in the
website

43
HIC 3e : Appropriate personal
protective measures are used by all
categories of staff handling bio
medical waste.

44
 The evidences that establish that
the hospital has followed HIC 3e
NABH standard are:
1. Availability of PPE.
2. Staff training on PPE usage
Evidences and hand washing.
3. Audit – PPE usage while
handling BMW.
4. Awareness among the staff –
interview.

45
 • Points to Remember
All healthcare professionals handling
BMW should:
• Be vaccinated against HBV and tetanus.
• Undergo health check up and training
at least once in a year.
Points to
A hospital having >30 beds should have:
Remember • A hospital waste management
committee.

46
ANTIBIOTIC POLICY

47
Antimicrobial
Stewardship Programme
• Antimicrobial stewardship refers to
coordinated interventions that are
designed to improve and measure the
appropriate use of antimicrobials in a
hospital. An antimicrobial stewardship
programme is a two-stepped process:
• Formulary restriction and
preauthorisation.
• Monitoring and feedback.

48
OUTBREAK
INVESTIGATION

49
• An outbreak may be defined as the occurrence of infections at a rate
greater than that expected within a specific geographical area and
over a period.

50
51
Continuous Quality Improvement
 The standards introduce the subject of continual
quality improvement and patient safety.

Continuous
Quality The quality and safety programme should be
documented and involve all areas of the
Improvement organization and all staff members.

The organization should identify and collect data

on structures, processes and outcomes, the
collected data should be collated, analysed and
used for further improvements.
 There is a structured quality improvement, patient
safety and continuous monitoring programme in the
organization

CQI. 1 Objective
Elements
There is a designated individual for coordinating and
implementing the quality improvement and patient safety
programme.
The quality improvement and patient safety programme is
a continuous process and updated at least once in a year.

Hospital Management makes available adequate

resources required for quality improvement and patient
safety programme.
 • The organization identifies key indicators to
monitor the structures, processes and
outcomes which are used as tools for
continual improvement
CQI. 2 • Objective Elements
a. Organization may identify the appropriate
key performance indicators in both clinical
and managerial areas.
b. These indicators shall be monitored.
 There is a structured quality improvement and
continuous monitoring programme in the
organization.

QA programme is
developed, implemented and
maintained by a multi-
disciplinary committee.

Covers all the major

elements related to quality designated individual for
improvement and risk coordinating
management.

Continuous process and updated at least

once in a year.
 Designated programme is
communicated and
coordinated amongst all the
employees of the
organization through proper
training mechanism.

Reviewed At Predefined
Intervals And
Opportunities For
Improvement Are Identified.

Audits are conducted at

regular intervals as a means
of continuous monitoring.
 There is a structured patient-safety programme in the
organisation.

patient-safety programme
maintained by a multi-
disciplinary committee.

The Programme Is Defined To

Include Adverse Events

NO HARM SENTINAL EVENTS

Designated
individual to
Continuous process and updated at least coordinate
once in a year.
 organization uses at least
two identifiers to identify
patients across the
organization.

Designated programme is Organization Adopts And

communicated and Implements
coordinated amongst all the
National/International
employees of the
organization through proper Patient-safety
training mechanism. Goals/Solutions.
The organization identifies key indicators to monitor the
CLINICAL structures, processes and outcomes which are
used as tools for continual improvement.

Patient Assessment. Clinical Research.

Safety And Quality
Control Programmes

Medication Parasurgical Services.

Management.
Anaesthesia

Infection Control Surgical Services.

Activities.
Blood And Blood
Products. Panchakarma Therapies
Availability And Content And Treatment
Of Medical Records. Procedures
The organization identifies key indicators to monitor the
MANAGERIAL structures, processes and outcomes which
are used as tools for continual improvement.

Procurement Of Reporting of Risk

Medication activities management.

Utilization Of Space,
Adverse Events And
Manpower And
Near Misses.
Equipment.

Availability And Content

Patient Satisfaction Of Medical Records.

Data Collection To
Employee Support Further
Satisfaction. Improvements.
The quality improvement programme is supported by the
management.

• Hospital Management makes available adequate resources required

for quality improvement programme.

• Hospital earmarks adequate funds from its annual budget in this

regard.

• The management identifies organizational performance improvement

targets.

• Appropriate statistical and management tools are applied whenever

required
 There is an established system for clinical audit.

Medical and Parameters are

nursing staff defined
participates

Patient and staff Remedial

anonymity is measures are
maintained. implemented.

All audits are

documented.
Incidents, complaints and feedback are collected and analysed to
ensure continual quality improvement.

• The organization has an incident reporting system.

• The organization has a process to collect feedback and

receive complaints.

• The organization has established processes for analysis of

incidents, feedbacks and complaints.

• CAPA are taken based on the findings of such analysis.

• Feedback about care and service is communicated to staff.

Sentinel events are intensively analyzed.

INTENSE
DEFINE ANALYSIS

Corrective and Preventive Actions are

taken based on the findings of such
analysis.
Summary
• CQI. 1 There is a structured quality
improvement, patient safety and
continuous monitoring programme
in the organization.
• CQI. 2 The organization identifies
key indicators to monitor the
structures,processes and outcomes
which are used as tools for
continual improvement.
 a. Those responsible for governance are
identified, and their roles and responsibilities
ROM.1. The are defined and documented. (Organogram)
b. Those responsible for governance lay down
organization the organization's vision, mission and values.
identifies those Mission, Vision and Values should be
displayed Prominently and Translated to Local
responsible for Language also
governance and c. Those responsible for governance approve
the strategic and operational plans
their roles are
and the organization's annual budget
defined. d. Those responsible for governance monitor
and measure the performance of the
organization against the stated mission.
e. Those responsible for governance appoint the senior leaders ( owner
will appoint CEO) in the organization.
f. Those responsible for governance support safety initiatives and quality
improvement plans
For e.g. The Reports of the safety and quality improvement
committees are shared and funds are allocated for corrective and
preventive actions.
g. Those responsible for governance support the ethical management
framework of
the organization
Transparency in handling complaints/grievances/research/clinical care
Code of Medical Ethics 2002 published by MCI is good guide to
Follow.
h. Those responsible for governance inform the public of the quality and
performance of services.
The governing board and head of the organization shall willfully develop
social responsibility policy for e .g free camps, adoption of village and
PHC .The organization should be aware of national health programme
like national blindness programme and vector borne programme.
 a. The leaders make public the vision, mission and
ROM.2.The values of the organization.
Display of mission vision and values in bilingual
leaders language
b. The leaders establish the organization's ethical
manage the management framework
The organization shall function ethically and
organization Transparent .The framework include code of conduct.
Code of medical Ethics – 2002of India.
in an ethical c. The ethical management framework includes
processes for managing issues
manner with ethical implications, dilemmas and concerns.
d.The organization discloses its ownership.
This disclosure can be in registration certificate /Quality
Manual/Display boards
e. The organization honestly portrays its affiliations and accreditations
NABH and NABL logo whever exist in a honest manner
ROM.3.The organization is headed by a leader who shall be responsible
for
operating the organization on a day-to-day basis.
a. The person heading the organization has requisite and appropriate administrative qualifications.
CEO and Director who takes the decision…Self explanatory
b. The person heading the organization has requisite and appropriate administrative experience.
c. The leader is responsible for and complies with the laid-down and applicable
legislations, regulations and notifications.
Interpretation: These include implementation and adherence to the requirements related to
Biomedical waste management rules, AERB requirements, PCPNDT Act, MTP act, Drug and
Cosmetic act and Narcotics Drugs and Psychotropic substances Act, Blood bank requirements and
Transplantation of human organs and tissue rules.
Examples of Notification : Guidelines and protocols for medicolegal care of victims/survivors of
sexual violence(MoHFW)
d. The leader (CEO) appoints/participates in the recruitment of senior
leadership (e.g. Medical Superintendent,Nursing Superintendent) of
the organization who will assist in the day-to-day functioning of the
organization
e. The leader ensures that each organizational programme, service,
site or department has effective leadership.
f. The performance of the organization's leader is reviewed for
effectiveness.
ROM.4. The organization displays
professionalism in its functioning
a. The organization has strategic and operational plans, including long-
term and short-term goals commensurate to the organization's vision,
mission and values in consultation with the various stakeholders
b. The organization coordinates the functioning with departments and
external agencies and monitors the progress in achieving the defined
goals and objectives.
c. The organization plans and budgets for its activities annually The
organization plans an budgets for its activities annually
d. The functioning of committees is reviewed for
their effectiveness.
The purpose of the committee; Frequency of its
meeting and monitoring of CAPA
e. The organization documents staff rights and
responsibilities
This should be done with the existing LABOUR
LAWS
f. The organization documents the service standards
that are measurable and monitors them.
h. Systems and processes are in place for change
management. (For e.g change of leaders,
infrastructure and change of instrument)
ROM.5.Management ensures that patient-safety
aspects and risk-management
issues are an integral part of patient care and
hospital management
a. Management ensures proactive risk management across the
organization ( Components of risk management plan includes
contingency plans and education and Training of Staff)
b. Management provides resources for proactive risk assessment
and risk reduction activities. (CAPA, and Contingency plan)
c. Management ensures integration between quality improvement,
risk
management and strategic planning within the organization.
d. Management ensures implementation of systems for internal
and external reporting of system and process failures.
For e .g in a case of breakdown of machine like CT or MRI , the
internal reporting is to be done to the head of organization and
external reporting to be done to the patients. The system of
reporting shall be documented.
e. Management ensures that it has a
documented agreement for all outsourced
services that include service parameters.
MOU with outsource facility like MRI
,Blood Banks, Laboratory etc should be done
at regular basis.
f. Management monitors the quality of the
outsourced services and improvements
are made as required
Once a year visit to all outsource facility
(Like BMW vendor ) should be done
HRM.1. The organization has a documented
system
of human resource planning

a .Human resource planning supports the organization's current and future ability to
meet the care, treatment and service needs of the patient.
b. The organisation maintains an adequate number and mix of staff to meet the care,
treatment and service needs of the patient.
c. The organisation has contingency plans to manage long- and short-term
workforce shortages, including unplanned shortages.
d. The job specification and job description are defined for each category of staff.
e. The organisation performs a background check of new staff.
f. Reporting relationships are defined for each category of staff
g. Exit interviews are conducted and used as a tool to improve human resource
practices.
HRM.2. The organisation implements a
defined process for staff recruitment

a. Written guidance governs the process of recruitment.

b. A pre-employment medical examination is conducted on
the staff.
c. The organisation defines and implements a code of conduct
for its staff.
d. Administrative procedures for human resource
management are documented
HRM.3. Staff are provided induction training
at the time of joining the organisation

b. The induction training c. The induction training

a. Staff are provided includes orientation to includes awareness on
and values.
with induction training the organisation's vision, staff rights and
mission responsibilities and

e. The induction training

d. The induction training
patient rights and includes training on staff providing direct
includes training on
responsibilities cardio-pulmonary patient care.
safety
resuscitation for

f. The induction training g. The induction training

includes training in includes orientation to
and control. organization
hospital infection the service standards of
prevention the

h.The induction training i. The induction training

includes an orientation includes an orientation service/programme's
on administrative on relevant policies and procedures.
procedures department/unit/
 Written guidance governs training and development
policy for the staff

HRM.4. There is an The organisation maintains the training record.

on-going
programme for Training also occurs when job responsibilities
change/new equipment is introduced.
professional
training and Feedback mechanisms are in place for
of training and development programme
improvement

development of
Evaluation of training effectiveness is done by the
the staff. organisation.

The organisation supports continuing professional

development and learning.
 Staff involved in blood transfusion services are trained on
the handling of blood and blood products.

HRM.5. Staff Staff are trained in handling vulnerable patients.

are Staff are trained in control and restraint techniques.

appropriately Staff are trained in healthcare communication techniques

trained based
e. Staff involved in direct patient care are provided
on their specific training on cardiopulmonary

job description resuscitation periodically.

f. Staff are provided training on infection prevention

and control.
 a. Staff are trained on the organization's safety
programme.
b. Staff are provided training on the detection,
HRM.6. Staff handling, minimization and
elimination of identified risks within the organization's
are trained in environment.

safety and c. Staff members are made aware of procedures to

follow in the event of an incident.
quality- d. Staff are trained in occupational safety aspects

related e. Staff are trained in the organisation's disaster

management plan.
aspects f. Staff are trained in handling fire and non-fire
emergencies.
g. Staff are trained on the organisation's quality
improvement programme
HRM.7. An
appraisal system a. Performance appraisal is done for staff
for evaluating the within the organization
performance of b. The staff are made aware of the system of
staff exists appra
as an integral part c. Performance is evaluated based on the
of the human pre-determined criteria.
resource d. The appraisal system is used as a tool for
management further development
process.
HRM.8. Process for disciplinary and grievance handling is defined and
implemented in the organisation

a. Written guidance governs disciplinary and grievance handling

mechanisms
b. The disciplinary and grievance handling mechanism is known to all
categories of staff of the organization
c. The disciplinary policy and procedure are based on the principles of
natural justice
d. The disciplinary and grievance procedure is in consonance with the
prevailing laws
e. There is a provision for appeals in all disciplinary cases
f. Actions are taken to redress the grievance.
 a. Staff well-being is promoted.
b. Health problems of the staff, including
HRM.9. The occupational health hazards, are takencare of in
organisation accordance with the organization's policy
promotes staff c. Health checks of staff dealing with direct
patient care are done at least once a yearand
well-being and the findings/results are documented.
addresses their d. Organisation provides treatment to staff who
health and sustain workplace-related injuries
safety needs. e. The organisation has measures in place for
prevention and handling workplace
violence.
 Personal files are maintained with respect to all staff,
and their confidentiality is ensured

HRM.10. There is The personal files contain personal information

documented regarding the staff's qualification, job description,
personal verification of credentials and health status.
information for each
staff member. Records of in-service training and education are
contained in the personal files.

Personal files contain results of all evaluations and

remarks.
HRM.11. There is a process for credentialing and privileging
of medical professionals, permitted to provide patient care
without supervision

a. Medical professionals permitted by law, regulation and the organization to

provide patient care without supervision are identified.
b. The education, registration, training and experience of the identified
medicalprofessionals are documented and updated periodically
c. The information about medical professionals is appropriately verified when possible.
d. Medical professionals are granted privileges to admit and care for patients in
consonance with their qualification, training, experience and registration.
e. The requisite services to be provided by the medical professionals are known to
them as well as the various departments/units of the organisation.
f. Medical professionals admit and care for patients as per their privileging
 HRM.12. There is a a. Nursing staff permitted by law, regulation and the
organisation to provide patient care without supervision are
process for identified.
credentialing and b. The education, registration, training and experience of
privileging of nursing nursing staff areappropriately verified, documented and
updated periodically
professionals,
c. The information about the nursing staff is appropriately
permitted to provide verified when possible.
patient care without d. Nursing staff are granted privileges in consonance with their
supervision qualification,
training, experience and registration.
e. The requisite services to be provided by the nursing staff are
known to them as
well as the various departments/units of the organisation.
g. Nursing professionals care for patients as per their
privileging
 Para-clinical professionals permitted by law, regulation and
HRM.13. There is a the organization to provide patient care without supervision
process for are identified.
credentialing and
privileging of para- The education, registration, training and experience of para
clinical clinical professionals are appropriately verified,
documented and updated periodically.
professionals,
permitted to provide
Para-clinical professionals are granted privileges in
patient care without consonance with their qualification, training, experience
supervision and registration.

The requisite services to be provided by the para-clinical

professionals are known to them as well as the various
departments/units of the organization

Para-clinical professionals care for patients as per their

privileging.
Information Management System
Information Management
System
• This chapter emphasizes the requirements of a medical
record in the hospital.
• As we know, the medical record is an important aspect of
continuity of care and communication between the various
care providers.
• The medical record is also an important legal document as
it provides evidence of care provided.
• The organization will lay down policies and procedures to
guide the contents, storage, security, issue and retention of
medical records.
IMS. 1
• The organization has a complete and accurate medical
record for every patient
• Objective Elements
a. Every medical record has a unique identifier.
b. Organization identifies those authorized to make entries in
medical record.
c. Every medical record entry is dated and timed.
d. The author of the entry can be identified.
e. The contents of medical record are identified and
documented.
IMS. 2
The medical record reflects continuity of care

Objective Elements

a. The record provides an up-to-date and chronological account of patient care.

b. The medical record contains information regarding reasons for admission,diagnosis and plan
of care.
c. Operative and other procedures performed are incorporated in the medical record.

d. The medical record contains a copy of the discharge note duly signed by appropriate and
qualified personnel.
e. In case of death, the medical records contain a copy of the death certificate indicating the
cause, date and time of death.
f. Care providers have access to current and past medical record.
IMS. 3
• Documented policies and procedures are in place for
maintaining confidentiality, integrity and security of
records, data and information
• Objective Elements
a. Documented procedures exist for maintaining
confidentiality, security and integrity of information.
b. Privileged health information is used for the purposes
identified or as required by law and not disclosed without the
patient's authorization.
 • Documented procedures exist for retention
IMS. 4 time of records, data and information
• Objective Elements
a. Documented procedures are in place on
retaining the patient’s clinical records,data and
information.
b. The retention process provides expected
confidentiality and security.
c. The destruction of medical records, data and
information is in accordance with the laid
down procedure.
 Documented policies and procedures exist to
meet the information needs of the care providers,
management of the organization as well as other
agencies that require data and information from
the organization.

Policy in compliance Information according

with the prevailing to the scope of
laws and regulations. services

All information management and technology

acquisitions are in accordance with the Documented
policies and procedures.
 The organization has processes in place for effective
management of data.

FORMATS for DATA Resources available for

collection standardized analysing data

Timely and accurate

dissemination of data

Storing and retrieving

data

Appropriate clinical and managerial staff participates in

selecting, integrating and using data
 The organization has a complete and accurate
medical record for every patient.
• Organisation identifies
authorized to make entries in
medical record

• Every record is DATED & TIMED

• AUTHOR can be IDENTIFIED

• Contents of medical record are identified Each medical record has a

and documented. unique identifier

• record provides an up-to-date and

chronological account of patient care.

• Provision is made for 24-hour availability

of the patient’s record.
The medical record reflects continuity of care.

CONTENTS OF MEDICAL RECORD

1. Reasons for admission, diagnosis and care plan.
2. Results of tests carried out and the care provided.
3. Operative and other procedures performed
4. date of transfer, the reason for the transfer and the
name of the receiving hospital.
5. copy of the discharge note duly signed
6. In case of death, copy of the death certificate
7. Care providers have access to current and past
medical record
 Documented policies and procedures are in place for
maintaining confidentiality, integrity and security of
information.
safeguarding of
maintaining data/record
confidentiality, against loss,
security & integrity destruction and
of information. tampering.

Health information
monitoring not disclosed
compliance of the Policy: access to
information in the without the
laid down patient’s
policy. medical record
authorization.
 Documented policies and procedures exist for
retention time of records, data and information.
Policy: retaining the
patient’s clinical
records, data and
information, in consonance
with the local and national
laws and regulations

Retention process provides

expected confidentiality and
security.

Destruction of medical records, data

and information is in accordance
with the laid down policy.
The organization regularly carries out review of
medical records.

• The medical records are reviewed periodically.

• The review uses a representative sample based
on statistical principles.
• The review is conducted by identified care
providers.
• The review focuses on the timeliness, legibility and
completeness of the medical records.
• The review process includes records of both active
and discharged patients.
• The review points out and documents any
deficiencies in records.
• Appropriate corrective and preventive measures
undertaken are documented.
 • IMS. 1 The organization has a complete and
Summary of accurate medical record for every patient.

Standards • IMS. 2 The medical record reflects continuity

of care.
• IMS. 3 Documented policies and procedures
are in place for maintaining confidentiality,
integrity and security of records, data and
information.
• IMS. 4 Documented procedures exist for
retention time of records, data and
information.