NABH Chapter 10 on Information Strandards.pdf

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Summary of Standards

The goal of information management in the organisation is to ensure that the right information is available to the

right person at the right time.

Information management includes management of hospital information system as well as all modalities of

information communicated to staff, patients, visitors and community in general.

Data and information management must be directed to meet the organisation's needs and support the delivery of

quality patient care. The information needs are provided in an authenticated, secure and accurate manner at the

right time and place.

Confidentiality, integrity and security of records, data and information is maintained. Confidentiality of protected

health information is paramount and is safeguarded across all information processing, storing and disseminating

platforms.

Information management also includes periodic review, revision and withdrawal of obsolete information to avoid

confusion among staff, patients and visitors.

The organisation maintains a complete and accurate medical record for every patient. Various aspects of the

medical record like contents, staff authorised to make entries and retention of records are addressed effectively by

the organisation. The medical record is available for appropriate care providers. The medical records are reviewed

at regular intervals.

Intent of the chapter:

Chapter 10

Information Management

System (IMS)

IMS.6. The organisation ensures availability of current and relevant documents, records,

data and information and provides for retention of the same.

IMS.1. Information needs of the patients, visitors, staff, management and external

agencies are met.

IMS.2. The organisation has processes in place for management and control of data

and information.

IMS.3. The patients cared for by the organisation have a complete and accurate

medical record.

IMS.4. The medical record reflects the continuity of care.

IMS.5. The organisation maintains confidentiality, integrity and security of records, data

and information.

IMS.7. The organisation carries out a review of medical records.

* This implies that this objective element requires documentation.

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STANDARDS AND OBJECTIVE ELEMENTS

Standard

Objective Elements

Information needs of the patients, visitors, staff, management and

external agencies are met. IMS.1.

d. A maintenance plan for information technology and communication network is

implemented.

a. The organisation identifies the information needs of the patients, visitors, staff,

management external agencies and community. *

f. The organisation ensures that information resources are accurate and meet

stakeholder requirements.

e. Contingency plan ensures continuity of information capture, integration and

dissemination.

g. The organisation contributes to external databases in accordance with the law

and regulations.

b. Identified information needs are captured and/or disseminated.

c. Information management and technology acquisitions are commensurate with

the identified information needs.

Commitment

Achievement

Excellence

Commitment

Standard

Objective Elements

Commitment

The organisation has processes in place for management and control

of data and information. IMS.2.

b. Data is analysed to meet the information needs.

e. Clinical and managerial staff participate in selecting, integrating and using data

for meeting the information needs.

d. The organisation stores and retrieves data according to its information needs. *

a. Processes for data collection are standardised.

c. The organisation disseminates the information in a timely and accurate manner.

Commitment

CORE

CORE Commitment Achievement Excellence

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Standard

Objective Elements

Commitment

The patients cared for by the organisation have a complete and

accurate medical record. IMS.3.

b. The contents of the medical record are identified and documented. *

d. Authorised staff make the entry in the medical record. *

e. Entry in the medical record is signed, dated and timed.

g. The medical record has only authorised abbreviations.

a. The unique identifier is assigned to the medical record.

c. The medical record provides a complete, up-to-date and chronological account

of patient care.

f. The author of the entry can be identified.

Commitment

Standard

Objective Elements

Commitment

IMS.4. The medical record reflects the continuity of care.

c. The medical record contains the results of investigations and the details of the

care provided.

d. Operative andotherproceduresperformedare incorporatedinthemedicalrecord.

e. When a patient is transferred to another organisation, the medical record

contains the details of the transfer.

g. In case of death, the medical record contains a copy of the cause of death report.

a. The medical record contains information regarding reasons for admission,

diagnosis and care plan.

h. Care providers have access to current and past medical record.

f. The medical record contains a copy of the discharge summary.

b. The medical record contains the details of assessments, re-assessments and

consultations.

Commitment

NABH Accreditation Standards for Hospitals

CORE

CORE Commitment Achievement Excellence