group 10 nabh
TRANSCRIPT
8/8/2019 Group 10 Nabh
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The journey to quality assurance through
accreditation has just begun ² the goals and vision so clear
Let us achieve them together ²because we all need them
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National Accreditation Board for
Hospitals and Health Care Providers
Chapter10
Information Management System (IMS)
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IMS.1
Policies and procedures exist to meet the informationneeds of the care providers, management of theorganization as well as other agencies that require dataand information from the organization
Presenter- Radhika
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*a) The information needs of the organization
are identified and are appropriate to the scope
of the services being provided by the
organization and the complexity of theorganization
*b) Policies and procedures to meet the
information needs are documented.
*c) These policies and procedures are incompliance with the prevailing laws and
regulations.
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*d) All information management and
technology acquisitions are in accordancewith the policies and procedures.
*e) The organization contributes to external
databases in accordance with the law and
regulations
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IMS.2
The organization has processes in place foreffective management of data
Presenter-Mohsin
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*a) Formats for data collection are standardized
*b) Necessary resources are available foranalyzing data
*c) Documented procedures are laid down for
timely and accurate dissemination of data
*d) Documented procedures exist for storing and
retrieving data
*e) Appropriate clinical and managerial staff
participates in selecting, integrating and using
data.
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IMS.3
The organization has a complete and accuratemedical record for every patient
Presenter- Roshni
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*a) Every medical record has a unique identifier.
*b) Organization policy 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 areidentified and documented
*f) The record provides an up-to-date and
chronological account of patient care
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IMS.4
The medical record reflects continuity of care
Presenter- Safiya
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*a) The medical record contains information
regarding reasons for admission, diagnosis and
plan of care.
*b) Operative and other procedures performed
are incorporated in the medical record
*c) When patient is transferred to another
hospital, the medical record contains the date
of transfer, the reason for the transfer and thename of the receiving hospital
*d) The medical record contains a copy of the
discharge note duly signed by appropriate and
qualified personnel
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*e) In case of death, the medical record
contains a copy of the death certificateindicating the cause, date and time of death.
*f) Whenever a clinical autopsy is carried out,
the medical record contains a copy of the
report of the same.
*g) Care providers have access to current andpast medical record.
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IMS.5Policies and procedures are in place for maintainingconfidentiality, integrity and security of information
Presenter- Ayan
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*a) Documented policies and procedures existfor maintaining confidentiality, security andintegrity of information
*b) Policies and procedures are in consonancewith the applicable laws
*c) The policies and procedures incorporatesafeguarding of data/ record against loss,destruction and tampering
*d) The hospital has an effective process ofmonitoring compliance of the laid down policy
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*e) The hospital uses developments in
appropriate technology for improving,confidentiality, integrity and security
*f) Privileged health information is used for the
purposes identified or as required by law and
not disclosed without the patient·s
authorization*g) A documented procedure exists on how to
respond to patients / physicians and other
public agencies requests for access to
information in the clinical record in accordance
with the local and national law.
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IMS.6
Policies and procedures exist for retention time of records, data and information
Presenter- Chaitanya
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*a) Documented policies and procedures are in
place on retaining the patient·s clinicalrecords, data and information
*b) The policies and procedures are in
consonance with the local and national laws
and regulations
*c) The retention process provides expectedconfidentiality and security
*d) The destruction of medical records, data
and information is in accordance with the laid
down policy
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IMS.7
The organization regularly carries out reviewof medical records.
Presenter- Chaitanya
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*a) The medical records are reviewed
periodically
*b) The review uses a representative sample
*c) The review is conducted by identified care
providers.
*d) The review focuses on the timeliness,
legibility and completeness of the medical
records
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*e) The review process includes records of both
active and discharged patients
*f) The review points out and documents any
deficiencies in records
*g) Appropriate corrective and preventive
measures undertaken are documented.
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