Medical Records Department (MRD) Policy
As per NABH Standards (Key Points)
1. Purpose
To ensure systematic management of medical records for easy retrieval, confidentiality, accuracy, and compliance with NABH and legal requirements.
2. Scope
Covers creation, maintenance, retrieval, storage, confidentiality, and disposal of medical records in the hospital.
3. Responsibilities
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MRD In-charge / Officer
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Supervise medical records management.
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Ensure implementation of MRD policies and procedures.
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Doctors / Nurses / Other Staff
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Timely and complete documentation in medical records.
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4. Policy Statement
4.1 Medical Records Maintenance
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Maintain complete, accurate, legible, and updated records for each patient (IPD, OPD, ER, Daycare).
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Use standardised formats and approved forms.
4.2 Content of Medical Record
Each inpatient file should include:
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Patient identification data
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Admission note & initial assessment
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Consent forms (signed & dated)
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Clinical progress notes
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Investigation reports
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Operative notes (if applicable)
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Nursing notes
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Discharge summary
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Medication charts
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Referral notes (if any)
4.3 Record Completion
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All records must be completed within 24-48 hours of discharge.
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MRD will notify departments for incomplete records and maintain an incomplete record list.
4.4 Numbering System
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Follow Unit Numbering System with Master Patient Index (MPI) for unique identification.
4.5 Filing & Retrieval
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Chronological and serial filing system for easy retrieval.
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Maintain an Out Guide system for tracking issued files.
4.6 Confidentiality & Security
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Ensure confidentiality of patient information.
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Records accessed only by authorised personnel.
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Do not share patient data without proper consent/legal order.
4.7 Retention & Disposal
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Maintain medical records for a minimum period as per law:
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IPD: 3-5 years (varies by state law)
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Medico-legal cases: indefinitely or as per legal requirement
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OPD: 3 years
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Follow proper disposal policy (shredding after approval from MRD in-charge & management).
4.8 Electronic Medical Records (if applicable)
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EMR to be password protected, with controlled access.
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Data backup done daily / as per IT policy.
4.9 Quality Indicators
Monitor MRD KPIs:
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Incomplete records rate
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Average time for record completion
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Retrieval time
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Accuracy of coding & indexing
5. Procedures
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Receiving Files: Receive from wards post-discharge, check for completeness.
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Coding & Indexing: Use ICD-10 coding system for diagnosis coding.
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Filing: File records in designated racks with location index.
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Issue & Return: Maintain issue register for files taken by departments.
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Archiving & Disposal: Archive as per retention schedule; dispose with confidentiality.
6. Training
MRD staff shall receive regular training on documentation standards, coding, confidentiality, and legal aspects.
7. Audit & Compliance
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Conduct periodic audits of medical records to ensure policy adherence.
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Non-compliance to be reported to Quality Manager and Management for corrective actions.
If required, I can draft this into a formal hospital policy document format with:
✅ Policy number
✅ Approval & review section
✅ Definitions
✅ Detailed procedures and forms list
✅ Footer with version control
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