Who can Audit ?  :  Doctors who Admit OR  Discharge , OR Member of treating team.                                                                                                                                                                                                                                                     Who can  Validate/Verify :  Peer from same Unit, Chief of Unit , HOD,  MS, IP SEO, MS Office and Quality Office.                             Key Performance Indicator(KPI) :  Automated

Department that maintains  Medical Record.( Accredited Broad Specialties  and Super Specialties)

The Admission Desk creates UHID. Corrections if any, to be made through Medical Records only as per policy. The BCMCH  UHID identifies Patient Name, Date of Birth, Address, and Contact Number. A Patient's Name is identified as on Govt ID/Equivalent for Bill Claims. Advisable that Infants be given an independent name after the birth notification is done. Names for Birth Registration Certificate / Proposed name for School Records are used.  Ref:AAC2b  5th ed

The Clinician in Charge or  Surgeon who admits, verifies treatment given by Team Members takes vicarious responsibility for the completeness of the Medical File  at time of admission. A Physician is Privileged for Clinical Care according to his credentials (education, Experience, and Additional Qualifications) and provided an Employee Code from HR. The Physician's Name, Signature, Seal/Employee ID, Date, and Time must be evidenced on IP Initial Assessment Form (HPE), Review Notes, Consent, Pre-Anesthetic Checks, Surgery or Procedure Done,  Discharge Summary and Medical Certificates. Counter signatures should be evidenced in situations where the Junior(s) writes notes for Senior Physician with Date and Time.  Reference : AAC4b. 5th ed.

Time of IA by the Physician after bed allocation in the WARD, written on History Physical Examination (HPE) sheet (Version 1.4).                                                                                                                                                                                                                       The time bed provided is recorded on the Activity Sheet. The BCMCH Policy for "the time for IA  is within 2 hours  of patient admission to ward in cold cases. Patient is triaged by a Reg. Nurse on arrival, prioritizes clinical needs, and informs Doctor.                                                                                                                                                                                                                            Documentation of time in IP File by Doctor must be aligned against the Triage Status for for Clinical status, Diagnostic test Results and Care Plan. Standard time for ED, Critical Care, and Wards triaged for Clinical status is Blue: Stat, Red <5 Minutes, Orange, 15 Minutes, and Green 30 -120 minutes. Maximum time in cold cases, in which IA is completed is 8-24 hours.                                                                                                                                                                                                                                                                             The time gets used for  Patients Outcome Analysis, Validation and Clinical Audits.  AAC4c. For details of the policy refer to home.bcmch.org> Quality> NABH Home> BCMCH Policies > BCMCH/POL/1001.05 Policy On Initial Assessment And Reassessment. * Standard : AAC 4a,b,c,d,e  of 5th Edn                                                                                                                          (This is a Previous Non Compliance in 2020 Assessment) "The Health Care Organisation has not defined the time frame for the IP initial assessment and is not monitoring the same."                                                                                                                                    

The Initial Assessment inference is by Triage,  Nutritional Assessment by History or BMI/ Percentile Chart ,Patient stability and Patient Risk analysis . The Admission Care plan written on EMR, OPD/EMR must be reviewed for Chronic Medications, appropriate Procedures, Diagnostic Investigations, special Diet needed after the Nutritional assessment, Referrals to Specialty and Support Departments, Informed Consent, Pre-Anesthesia Checks, and Preoperative Safety checklist etc . A review initial assessment, can be documented in IP file within the  2- 24 hours (a second time or in a paraphrased manner after arrival to ward) by Senior.                                                                                                                                                                                                   Note 1 : No box on the top of  initial assessment sheet (version 1.4) must be left empty as Nutritional evaluation, identification of Allergy, and Vulnerable patient is mandatory.  A comment that links Ward assessment to an earlier assessment made elsewhere  is permitted. Review or Verified findings to be entered again as per the patient condition by Treating doctor on review (paraphrased version ).                                                                                                                                                                                                                                                                                                                                                                                                                                                  Signature by Junior on behalf of Senior in the Medical File is not legal. ref: AAC-4a, AAC-4f                                                                      Note 2 : Patient Risk Analysis  predicts  the prognosis/ expected outcome at arrival IP File .                                              Vulnerability includes Physically and  mentally Challenged, Semiconscious, Unconscious, on immunosuppressants, Chemotherapy), Age below 1 year and over 65 years, Known Allergy (Y/N) and Abnormal Nutritional Status, Comorbidity with Chronic using Chronic medication, Complication of Disease already present at admission like Congenital, Metabolic Problems or High Risk Pregnancy, that will affect the current inpatient management.                                                                                                                                                                                               Note 3 : High Risk Patients must be identified.The risk documentation AND counselling must be included at admission. (Examples include  issues that predict prolonged Length of Stay (LOS) beyond 5 days, those that make a patient Vulnerable to Pressure Sore, Deep Vein Thrombosis, Patient Fall , Sentinel event, or Near Miss event) .                                                                                                                                 High, Medium or Low Risk  Documentation with expected outcome and Patient counseling according to risk analysis, at admission, is very important for Employee Safety. Absence of documentation is considered an  Error of Omission. (Previous Non Compliance in 2020 assessment-"The Health Care Organisation has not completed IP initial assessment uniformly as per checklist/ time frame/ nutritional screening")   Nutritional Screening ( History of Loss of weight in last three months or Loss of Appetite for last one week .Assessment as  Percentile/ BMI evaluation )  Not applicable : write  NA  as in unconscious / fracture

Treatment or Care Plan can be initiated in the Initial Assessment by a Junior Doctor in ED or OP but the same should be countersigned and authorized by the treating doctor within 24 hours with  Sign, Employee, ID /Seal  Date and Time. Ref AAC 4 (e,f,g) 5th Edn.                                                                                                                                                                                             (Previous Non Compliance from 2020 assessment) -"The care plan is not countersigned by the clinician in-charge of the patient within 24 hours. The Health Care Organisation has itself documented compliance to be 4.9 % in the month of Nov, but no Root Cause Analysis or Corrective Action Preventive Action has been evidenced").

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(These refer to Additional medications taken by the patient from Home for other conditions /initiated in MDCCU with step down to Ward, transfer from Ward to Superspeciality during Take over. These must be written at Initial Assessment, and also prescribed on Medication Sheet by the Qualified Person. It is relevant when  It is documented in the corresponding area of the Medication chart and in Handover notes ).

Forms should be comprehensive and complete with Indication for Referral, Urgency, or Routine. Date / Time by both parties. The Referral / Cross Consultation forms should have relevant details of the patient's clinical condition Doctors  Identification (SNDT). The referral is complete if marked 1.Emergency  (stat) 2. Priority (As soon as possible) 3.Urgent (within 8 hours of the working day), 4. Routine (<24 hours ). For an emergency referral, request to be relayed by telephone in addition.  Uniformity can be made as per Speciality Department Template / Manual. Ref AAc3c, AAC12f                                                                                                          (Non-Compliance in the previous assessment in 2020- "While the organization has laid down guidelines to identify early warning signs of change or deterioration in clinical conditions for initiating prompt intervention, the staff is not aware of how and when to take action to escalate the same").                                                                                                                                                                            (Previous Non-Compliance,  2020 -"The procedures which guide the referral of patients to other departments/ specialties do not mention whether the referral is for opinion, co-management and takeover. While It is graded into immediate, urgent, priority, or routine category, there is no defined time frame for each category to be seen")

First Plan of Care, Initial Assessment review on Day 1  has to be followed by Daily Review on Day 2 and every 12 hours  in 24 hours daily (Morning, Evening, Bedtime Review by on call as required). Once every 8 hours in Critical care -stable patients. Additional entries may be done in Unstable Patients. A Problem-Oriented Medical Record (POMR) has to address new Problems on a daily basis, along with Action plan and Medication review (Routine). Patients are thus reassessed daily after admissions and at appropriate intervals till discharge. The response to treatment and revised plans made are documented daily. The periodicity can be determined by the Clinical condition. Early Warning Scores/ Standard guidelines  can be used for uniformity in Specialities. (NC) Ref AAC 5. (a, c, d, e)  5th Edn. (Non Compliance 2020 - "For procedures done outside the OT, there are no documented procedures to prevent adverse events like a wrong site, wrong patient and wrong procedure.  Patients should be counselled as needed").  (Non Compliance 2020 - "The organisation has documented admission and discharge criteria for the ICUs . There is also no evidence that patients and families are counselled by the treating medical professional at periodic intervals in the ICUs").

Notes are Signed, Named, Dated, Timed (SNDT) at Initial Admission, and with all entries by Physician *Check whichever is available. If sign, name, date and time is not available select "None" (Non Compliance 2020 - "All entries in the medical record are not uniformly named, signed, dated and timed . The author of each entry cannot always be identified").

STATUTORY mandates a legible prescription with 8 rights: Right Patient, Right Medication, Right Indication, Right Dose, Right Frequency, Right Time, Right Duration, and Right Route. EMR Prescription is possible through HIS.14.  Medication orders on Drug sheet: Written in Generic completely on admission.(All those medications where generic name can be written must be written so- For other combinations Trade name can be entered and the response should be marked - Partial)

*Whether the action/intervention for critical value alerted from Para clinical department (Panic Value - not Abnormal Value )is documented appropriately in the patient record by the physician? * Refer to NABH 5th Edition standard AAC 6g;  AAC 9g  for requirements.                                                                                                                                                                                            (Non-Compliance 2020 - "There is no evidence that the organization has a mechanism in place to monitor whether the adequate clinical intervention has taken place in response to a critical value alert").                                                                                            Listed Panic Values / Critical Values, noted in EMR with red asterisk get relayed directly by Lab Personnel. The Corrective Intervention taken for these results must be documented in the daily Review Notes of the IP File. Choose options provided in the template for Discharge Summary in HIS . AA6g, AAC12h

Patients bystanders should be updated after daily review. Documentation should also be made in the progress notes regarding the communicant,s Name, time, and details communicated                                                                                                                                             (Non-Compliance 2020 - "There is no evidence that the organization has a system for effective communication with patients and /or families").

Handovers are documented in Medical File in Critical Care Areas in addition to the Review notes by Intensivists, Hand over Sheets in ICU/NICU, and Registers in Wards) by the duty Physician. Review of Patient's condition, relevant investigation that needs to be done/ follow up, after regular working hours, must be written.  Additional Notes of review, by Duty Doctor for these specified Patients is Mandatory in ICU and desirable in Wards. Periodicity of notes to be determined by Patients Clinical  Status.AAC12d.                                                                                                                                                                                           ICUs already have a Doctors handover notes as part of medical file. A register should be maintained in the ward for recording handover details- It is filled if there is any duty to be carried over between shifts. if not the space of that shift can be left blank. *Refer to NABH 5th Edn AAC 12d                                                                                                                                                                                      (Non Compliance 2020- "Completeness of Handover Communication each day/shift in Medical file/ Ward Register as appropriate.")

Consent Forms should contain Details of Surgery , Procedure Specific Complications, Anesthesia Specific Complications and Patient-Specific Complications anticipated. Benefits, Possible Risks, and Alternatives for the named Procedure  must also be written on Consent Form in addition to Counselling. The validity for informed consent is 4 weeks for surgery.                   COP13b *Refer to NABH 5th Edn PRE 2g, PRE 4a,b, c,d,e ,COP 7e, COP 12 b, COP 13b, COP 14c, for requirements. (Select NOT APPLICABLE if there is no consent is required.                                                                                                                                        (Non Compliance 2020 - "The consent form does not specify the name of the doctor in training when he / she is performing the  the procedure .  Details of Procedures are not documented accurately in the patient record").                                                                               (Non Compliance 2020 - "The list of situations where informed consent is required was not evidenced. Informed consent does not include information regarding 1. the surgery or 2. anesthesia 3. the risks, 4. benefits or 5.alternatives.6. The transfusion consent does not include risks, benefit and possible complications of multiple transfusions").

This Standard Checklist Includes Patient identification tags, badges, cross-checks, time outs.                                                                                                            Refer to NABH 5th Edition standard COP 7d, 7e, COP 14d for requirements.                                                                                                            (Non-Compliance 2020 - "The timings of time in, time out, and sign out in the WHO surgical safety checklist are not uniformly documented").

PAC Validity is for four weeks. Anesthesia assessment should mention pre-medications, Type of Anesthesia, Special requirements, and anticipated post-anesthesia care where appropriate.                                                                                           When anesthesia is required on an urgent basis the pre-anesthesia assessment and pre-induction assessment can be performed one after another or simultaneously but documented separately. (COP 13c).                                                                                                                                                                                                                     (Non-Compliance 2020 - Monitor unplanned ventilation /anesthesia/percentage of unplanned ventilation following anesthesia. / Use  Revised Audit Sheet for anesthesia. Re-scheduling of patients only includes postponement of cases to the next day and not those cases rescheduled beyond four hours. The percentage of cases who received appropriate prophylactic antibiotics within the specified time frame is shown to be 100%, whereas on verification it was found that time of administration is not being captured and in some cases, either the antibiotic was not given or an inappropriate antibiotic was given

A second PAC assessment ( Pre Anesthetic) is done one day prior to Surgery and documented in PAC Form or Clinical Notes .As validity of first PAC is four weeks a revaluation is needed especially for elective cases.When anesthesia is required on an urgent basis the pre-anesthesia assessment and pre-induction assessment can be performed one after another or simultaneously but documented separately. (COP 13 c).    

 A (Pre- Operative ) Check is made one hour before skin incision. The patient is re evaluated while in the holding area, or prior to Skin Incision. (COP 13 c). This is for elective and emergency cases for Correct Indication, Prophylactic antibiotic, Anesthesia Modification, Change in Medication.The Safety Checklist signatures are taken from Surgeon, Anesthetist, and Nurse. COP 7d, COP12a . The WHO surgical safety checklist to be uniformly documented.                                                                                                                                                   (Non-Compliance 2020 - Monitor unplanned ventilation /anesthesia/percentage of unplanned ventilation following anesthesia / . Use  Revised Audit Sheet for anesthesia. Re-scheduling of patients only includes postponement of cases to the next day and not those cases rescheduled beyond four hours. The percentage of cases who received appropriate prophylactic antibiotics within the specified time frame is shown to be 100%, whereas on verification it was found that time of administration is not being captured and in some cases, either the antibiotic was not given or an inappropriate antibiotic was given. * Ref COP 13a,b,c, d, e, f, g, h, I, j.   (Non-Compliance 2020 - "There is no evidence that an immediate preoperative re-evaluation is performed since no parameters are recorded, nor is the time of evaluation noted. Monitoring of percentage of unplanned ventilation following anesthesia only mentions the reasons as ‘major surgery’/ ‘sick patient’").

This is applicable for  Surgery in OT and Procedural sedation outside the theatre as well. Ref COP 7g,h, COP 14.  A note on the well being of the patient after Procedure or Surgery by the Surgeon/ Team Member is mandatory.                                                                                                                                                                                                              (Non-Compliance 2020 - "The level of sedation is not being monitored outside OT.  Intraoperative anaesthesia monitoring does not uniformly include end-tidal CO2 in OT").

All elective discharges should be planned at least 24 hours in advance AAc 13 e AAC 4g- it should preferably be recorded in the progress notes as Discharge Notification time and informed to the staff. This helps to initiate services like Nursing Activity Sheet, Partial Billing, provide Medical Reports, Lab Results or complete Insurance Forms thereby decrease the time for discharge activity. The start point for calculating the time taken for discharge is when the treating doctor declares/documents that the patient is fit for discharge.

*A Discharge Summary includes Name, UHID, Name of treating Doctor, Dates of admission And Discharge,the  reasons for admission, significant Clinical findings, Investigations, Medications,Treatment given,procedure performed,Followup advice ,medications and instructions. AAC14 Final Diagnosis, Medications ,When Where to Return on Follow Up, How/Which Contact number to seek for help. Special needs and Specific Red Flags for the Specific Patient diagnosis, to return earlier than advised must be documented if any. Additional advice on Diet, Rehabilitation, Diagnostics if required may be included. Department Specific templates to be made.    AAC 4g, AAC12a,AAC13a, AAC13d,AAC 13e,AAC AAC 13f 12f, AAC14                                                     Final diagnosis to be filled at discharge on the Final Summary Sheet. Procedures include Dialysis, Chemotherapy, Holter Monitoring, Endoscopy, and Invasive Procedures that require Sedation.                                                                                                                                                                                                                                                                                                                  Note: Reference used for Final Diagnosis: International Classification of diseases (ICD 10), Tenth revision, Alphabetically  Indexed in 3 volumes,5th edition printed 2016,  is used currently by Medical records.HIS incorporation of ICD 10 version 10 is in the Pipeline. ICD Codes for  Major  Diagnosis from General Medical and General Surgery Departments are currently assigned by Medical records. Providing ICD Codes help in retrieval of file /data for Institutional research.                                                                                                                                                                                                                                                                                          All admitted patients including DAMA must have a Discharge Summary AAC 13 d.                                                                                 In case of death : Certified with Cause of Death. * Refer to NABH 5th Edition standard AAC 14a.b.c,d,e,f,g,                               Partial Discharge summaries, Discharge Medications may be done on online specific templates prepared. Provisional Bills can be viewed by Nurses online the PREVIOUS day. EMR can be used to decrease the Turn around Time to write a partial Discharge summary the previous evening . Patient satisfaction score soars with a quick send-off by admitting Doctor on the  Patient Feedback form. AAC13f                                                                                                                                                                            (Non Compliance 2020 -  While how to obtain urgent care is mentioned, the discharge summary does not uniformly incorporate instructions about when to obtain urgent care).                                                                                                                                                  (Non Compliance 2020 - The batch and serial number of the implantable prosthesis and medical devices are not recorded in the discharge summary.)

* The start point for calculating the time taken for discharge is when treating doctor declares that patient is fit for discharge. The end point is when patient actually  vacates the bed. AAC 13 after payment of hospital bill. BCMCH mandates the Patients whose Length of stay is >4 days  should have a planned discharge to enable them leave hospital by 12 Noon . *Refer to NABH 5th Edition standard AAC 13 and AAC 14.                                                                                                                                          Achieve the goal "Go home by Lunch" in the majority. After 9 am rounds, the patient should be able to clear his bills, file an insurance claim by noon after collecting Discharge Summary and Medications.

This Clinical Outcome Review by a Peer  reveals the gaps, deficiencies and Non Compliance in IP File Documentation, along with Clinical Management for Corrective and Preventive Actions (CAPA) as required.Root Cause Analysis of DAMA patients has to be documented on the day of discharge in the file . This may be verified by the MS Office or Administration.    

All Mortality Files must have the Copy of Government Death Certificate with details. Mortality Review is mandatory for all deaths , before the file is dispatched to Medical Records in 24 hours. A review of the Mortality Case File by the Administrative  head or the Unit is a fact-finding exercise, a teaching tool  and is not used for punitive measures in an accredited Medical College Hospital. Documentation of review of the expired Patient IP Files  by Unit Head with Name and SNDT should be evidenced in the file AND  online for the collection of  Mortality KPI from January 2020 for record purposes.The details of Medical Report by HOD to be kept Confidential by the Administrative HOD and not in the IP File.  AAC14G                                                                              All Patient death must be Reviewed by Unit Head/ Speciality Health preferably within three working days by Head of Unit  with a note of review completion  with SNDT ).                                                                                                                                                                (NC 2020- For clinical audits, the parameters to be audited are not defined by the organisation. All audits do not have a checklist with the predefined parameters. Remedial measures are not implemented)

For Peer Review, Validation by Quality Office, Discharge against  Medical Advice (DAMA) or Clinical Audit Purpose.  Fish Bone analysis in DAMA situation includes Changes in Practice (Methodology), Improvements in Physician Knowledge (Training), Equipment availability or Faults, Change in Consumables Used, Improvement in Facility, Cost Factor.  Employees are encouraged to provide feedback to MSO and Management in writing as specific patient scenario.                                                                 Patient Feedback Questionnaire with Scores for Medical , Nursing , Pharmacy, PCS and Billing is collected. (NC 2020 - For clinical audits, the parameters to be audited are not defined by the organisation. All audits do not have a checklist with the predefined parameters. Remedial measures are not implemented).