STANDARD OPERATING PROCEDURE

TITLE:
Policy and Procedure for Maintenance of Medical records of Patients

PURPOSE:
To provide guidelines to the medical team for making medical records in such a way
that it remain useful for all the stake holders. To make all medical records Clear,
concise, complete, correct and accessible for all stake holder while maintaining the
security and confidentiality of information to the highest level; to enhance the quality
of patient care at Jag Pravesh Chandra Hospital.

POLICY:
A Medical Record shall be maintained for every individual who is evaluated or treated
as an inpatient, (outpatient, or emergency patient) of a JPC hospital (Currently
Records of Outpatient and emergency patient is not being maintained.) in 1st phase
records of emergency patient shall be maintained and subsequently records of OPD
shall also be maintained in MRD.
All Patient Records are confidential and once received in MRD it is the responsibility
of MRO/ I/c In-charge to maintain it. No records should be shown to any
unauthorized person. Any movement/ Photocopying of record (Within or outside the
hospital such as court etc.) to be done only on receipt of formal request, all such
request are to be filed.

SCOPE:
Hosital wide

RESPONSIBILITY:
Medical care team
PROCEDURE:
a. Admission record must contain reason for admission of the patient,
admitting diagnosis and plan of care, or it must be recorded not later than
48 hours after admission.
b. Only authorized members of the medical care team are allowed to make
entry in to the patient's medical records.
c. Every page in the medical record should include the patient’s name, CR
number and unit name.
d. The contents of the records should have a standardized structure and
layout. Where possible medications should be identified using their
generic name.
e. Documentation within the record should reflect the continuum of patient
care and should be viewable in chronological order.
f. Data communicated on, Medical/ surgical procedure, Blood or blood
product transfusion, admission, handover and discharge should be
recorded using a standard Performa (Surgical safety checklist, transfusion
checklist, Admission summary, Discharge summary, Transfers summary
etc.)
g. Every entry must be timed, dated, legible and signed by the person
making the entry. The name and designation of person making the entry
should be legibly written/ stamped against their signature. Deletion and
alterations should be countersigned.
h. Every entry should identify the most senior healthcare professional
present (who is responsible for decision making) at the time the entry is
made, on each occasion the consultant responsible for the patient’s care
changes, the name of the new responsible consultant and the date and
time of the agreed transfer of care should be recorded.
i. An entry should be made in the medical record whenever the patient is
seen by a doctor or any healthcare professional. When there is no entry in
the hospital record for more than two days the next entry should explain
why.
j. The discharge record/ discharge summary should be commenced at the
time a patient is admitted to hospital
 k. Advance directives,(such as peri-operatve orders, instructions,
medications, precautions, consent and resuscitation status statements
must be clearly recorded in the medical record.
l. Upon discharge/Death/LAMA/DAMA/ Transfer; the original patient
file with all documents and investigation reports ate to be sent to MRD.
m. It is responsibility of the concerned department to complete the patients
records in every respect, any deficiency observed/ find during check in
MRD should be attended promptly by the concerned doctor. File once
moved to MRD should not be recalled for entry, all entry are to be made
in MRD only.
n. Entry of reports, Opinion should preferably be done before the discharge
of patients in all Medico legal cases, however if it is not possible for any
reason concerned doctor should visit MRD to complete records, no MLC
should be recalled from MRD for any reason.
o. It is Duty of the concerned HOD to complete all Medico legal records
either by directing the concerned Resident doctor/ Specialist, Medical
officer if the concerned doctor is not available for any reason HOD must
ensure the completion of record, or he himself complete the record at the
earliest, He may record the reason for doing so in file.
p. All entries made by Resident doctor must be countersigned by Concerned
HOD or Specialist of the department (To be authorized by HOD)
q. Any deficiency pointed out by MRD should be rectified by any
authorized member of the medical care team at the earliest by visiting the
MRD. Records once submitted in the MRD cannot be recalled in the
department. However Department can recall patient record in the event
of Readmission of the patient by sending a Formal request on Medical
(Record Recall Performa)

FORMS AND FORMATS:

1. MRD check List
2. Clinical Audit Checklist
3. Medical Record Recall Performa.
EFFICIENCY CRITERIA:
1. Percentage of Incomplete medical records received in MRD.
2. Department wise % of Incomplete medical records received

REFERENCES:
1. Guidelines for Medical Record and Clinical Documentation ; WHO-SEARO
coding workshop September 2007

DOCUMENTATION & REPORTING: