Title Page
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Conducted on
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Prepared by
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Location
Self-Assessment Questions
INPUT
Planning, Execution and Monitoring System
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Has an existing Manual of Procedures or Operations Manual
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Has an approved Departmental Plan
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Compliant with the applicable Standard Staffing Pattern
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What is the current total count of employees assigned in MRD?
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All staff received Learning Development Intervention (training, orientation, re-orientation, coaching, mentoring, seminar, webinar, etc.)
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Specify the name of the staff, and the title of the training attended, and include the date of training.
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Provided with office and storage space compliant with MOH standards
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Provided with designated space for completion of patient record
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Proper lighting, ventilation, and temperature of storage area
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Provided with office equipment: adequate and appropriate working tables, filing cabinets, and mandatory office equipment and materials
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Specify the details of concerns encountered in this question
Administration and Supervision
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Regular Conduct of MRD Meetings
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When was the last meeting conducted? Attach a copy of the last minutes meeting.
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Functional Medical Records Committee (MRC)
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When was the last conduct of MRC? Attach a copy of the last minutes meeting.
PROCESS
Medical Record Creation
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With established Patient Record Identification System
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Maintain/Update a Standardized Patient Record for every patient assessed or treated
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Duly accomplished consent form should accompany each patient's medical record
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Authorized personnel to make entries in the medical record are clearly defined as per Hospital Policy
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Abbreviations and symbols used in medical records are following WHO or approved by the health facility upon recommendation by the MRC
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Data of Patients receiving emergency care includes: time of arrival and departure, conclusion at the termination of treatment, patient's condition at discharge, and follow-up care instructions.
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Assign ICD-10 codes to Diagnoses
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Observe proper use of copy and paste function when electronic medical records are used
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Check OPD and In-patient Records include all the necessary information based on the Standard
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Patient record follows Standard Health record arrangement
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Observe “ALERT” notation for conditions (i.e., allergic responses and adverse drug reactions) prominently displayed on the cover sheet.
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Include the patient's past medical history and a sufficiently detailed report of a relevant Physical Examination (PE) completed within 24 hours upon admission
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Reflect Therapeutic and Special diagnostic test orders
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Record Progress Notes, observations, and consultation reports
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Complete admission and discharge record with all the diagnoses and procedures at the time of discharge or as soon as all relevant information is available
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Check admission and discharge records use terminology based on the International Standard Nomenclature of Medicine
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Discharge summary contains the following: Discharge diagnosis, Procedures performed, Follow-up arrangements, Therapeutic orders (home medications), and Patient home instructions
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Certified true copy of the discharge summary is present when a patient is discharged or transferred to another facility
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Autopsy report is filed when applicable, with provisional diagnosis noted within 72 hours
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Incomplete patient records must be completed; diagnostic results must be submitted and attached to patient records
Medical Record Documentation
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Completeness of patient records with no missing or detached form is present
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Documents are legible and written in ink or typewritten
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Written documents, including policies, procedures, and programs, are updated as necessary
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MRD staff assists the attending physician in reviewing records for completeness
Medical Record Storage and Safekeeping
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Inactive records are transferred to inactive filing storage to give way to the incoming records, decongest the area, and facilitate retrieval
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MRD has a good and efficient retrieval system following policies and standards
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The hospital safeguards all information contained in the patient record against loss, destruction, or unauthorized use
Medical Record Accessibility
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All information in the patient record treated as confidential and disclosed only to authorized individuals
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Release information with or without clinical value is done only with written consent/waiver from the patient
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Hospital policy on releasing non-clinical information (name, address, attending physician, relative staying with patient during admission, admission, and discharge dates) is present
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Updated policy on releasing patient records outside healthcare facilities and use for research and insurance providers is present
Medical Records Systems and Procedures
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Policy on patient record identification system in place and implemented
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Established proper assembly of patient records
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Policy on the arrangement/structure/format of the content of patient records in place and implemented
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Documentation guidelines implemented
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Policy and procedures on the analysis of patient records, quantitative and qualitative analysis of patient records done in accordance to policies and procedures
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Disease indexing correctly carried out
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Policy/ procedure on the filing of patient records in place and implemented
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Established proper filing and storage of patient records
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Maintaining and updating Procedure on Retrieval of Patient records
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Policy and Procedure on Retention and Disposal of Patient Records
ICD Coding
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MRD staff trained on the latest ICD and clinical coding
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Patient records conform with the latest ICD and clinical coding
Medico-Legal Aspects of Health Record
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Consents and certificates properly filled out with complete and accurate clinical data before its intended use
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Policy and procedure on handling telephone inquiries on demo data and clinical information
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Policy and procedure on dealing with MRD clients requesting for patient's clinical information
Continuous Quality Improvement (CQI)
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Trained staff on the development and implementation of CQI
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Implements CQI for MRD
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Conducted CBAHI Self-Assessment 2023?
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What is the obtained score? Attach a copy of the total score of the self-assessment.
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What are the sub-standards requiring corrective actions?
Risk Management
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Trained staff on the development and implementation of Risk Management
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Implements risk assessment and management for MRD
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Please specify the identified risks related to Medical Records Department
OUTPUT
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Relevant reports prepared for use in the management process
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What are the reports prepared?
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Submission of timely and accurate report required by the TQM, MOH, and other agencies
