BEDI HOSPITAL
Issue date: 01.05.2025
AH / NABH Management Centered STANDARD Issue No.: 00
FOR SHCO / Information Management System Rev. date: Nil
/REFERENCE: NABH 3rd Edition Rev No.:00
Effective Date: 02.05.2025
CONFIDENTIALITY OF INFORMATION
POLICY: All the patient and non-patient related data and information generated, provided or
contained in the hospital to be kept confidential and secured.
PURPOSE: To maintain the confidentiality, integrity and security of information.
DEFINITION: Nil
ABBRIVIATAION:
MRD= Medical record department
HMS= Hospital Management System
IT= Information Technology
SCOPE:
All the information generated in the hospital. This policy is applicable to following
Patient Information contained inHMS
Data and information in HMS regarding various use of hospital management andanalysis
Information in Medicalrecords.
Information kept in manual registers, forms andfiles
Hospital Personnel’s information in their personnelfiles
RESPONSIBILITY: All hospital staff
DISTRIBUTION: Hospital wide
PROCEDURE:
All patient and non-patient related data and information generated, provided or contained in the
hospital shall be kept appropriately confidential, integrated and secured.
All information concerning a user, including information relating to his / her health status,
treatment or stay in the hospital shall be kept confidential.
No person may disclose any information contemplated in above mentioned point unless,
The user consents to that disclosure inwriting
A court order or any law requires such disclosure;or
Non-disclosure of the information represents a serious threat to publichealth
Prepared by Approved by
Mr. Sumit
Dr. Bedi
BEDI HOSPITAL
Issue date: 01.05.2025
AH / NABH Management Centered STANDARD Issue No.: 00
FOR SHCO / Information Management System Rev. date: Nil
/REFERENCE: NABH 3rd Edition Rev No.:00
Effective Date: 02.05.2025
Without prejudice to the generality of this section, special precautions for the maintenance of
confidentiality shall be taken, with respect to
Persons affected with HIV / AIDSand
Persons with mental healthproblems
Person is danger to national security or to thesociety
This shall be in accordance with Indian Evidence Act, Indian Penal code, Code of Medical
ethics.
These records shall be safe guarded against loss, destruction and tampering. Adequate space,
cleanliness and storage furniture shall be maintained in Medical records department
Privileged health information shall be used for the purposes of medico legal cases only.
Patient /physician and other public agency requesting for access to medical records shall be done
as per policy “Access to Medical record”
IMS Electronic records:
These records are kept in HMS and include patient related information, administrative
information and various reports.
Following shall be done to keep the confidentiality, integrity and security of this information.
1. Access shall be restricted and only through User ID andpassword
2. User ID and Password shall be provided to identify personnel depending on the type of
information required by him for hisjob.
3. The IT department shall provide the right to access only after clearance from Medical
Director.
4. Right to access shall be provided only after properjustification.
5. Backup of all information and data shall be automatically eveningday.
6. Internet facility is given in specificcomputers.
7. Electronic data shall be protected from virus / Trojans and other computerbugs.
Medical records:
1. Access to be provided as per document ‘Response to request for access to information
in medical records.
2. Medical records for admitted patient shall be kept under custody of nursing staff andshall
not be accessible to people not involved in the patientcare.
Prepared by Approved by
Mr. Sumit
Dr. Bedi
BEDI HOSPITAL
Issue date: 01.05.2025
AH / NABH Management Centered STANDARD Issue No.: 00
FOR SHCO / Information Management System Rev. date: Nil
/REFERENCE: NABH 3rd Edition Rev No.:00
Effective Date: 02.05.2025
3. A proper track of medical records shall be kept in case these records are transferred from
one place toanother.
4. It shall be ensured by health care staff and medical records department that all pages and
contents in the medical records and appropriately kept and are prevented from loss,
tampering or destructions. No loose paper shall be allowed in medicalrecords.
Activity and Procedure:
S. Activity Responsibility
No
1 All patient and non-patient related data and information All hospital Staff
generated, provided or contained in the hospital should be
kept appropriately confidential, integrated and secured.
2 All the protocols for electronic records and medical Medical record
records must be followed (oncall). department & IT
Department
REFERENCES: Nil
RECORDS AND FORMATS: Case Files
Prepared by Approved by
Mr. Sumit
Dr. Bedi
