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Self-Assessment Questions


Planning, Execution and Monitoring System

  • Has an existing Manual of Procedures or Operations Manual

  • Has an approved Departmental Plan

  • Compliant with the applicable Standard Staffing Pattern

  • What is the current total count of employees assigned in MRD?

  • All staff received Learning Development Intervention (training, orientation, re-orientation, coaching, mentoring, seminar, webinar, etc.)

  • Specify the name of the staff, and the title of the training attended, and include the date of training.

  • Provided with office and storage space compliant with MOH standards

  • Provided with designated space for completion of patient record

  • Proper lighting, ventilation, and temperature of storage area

  • Provided with office equipment: adequate and appropriate working tables, filing cabinets, and mandatory office equipment and materials

  • Specify the details of concerns encountered in this question

Administration and Supervision

  • Regular Conduct of MRD Meetings

  • When was the last meeting conducted? Attach a copy of the last minutes meeting.

  • Functional Medical Records Committee (MRC)

  • When was the last conduct of MRC? Attach a copy of the last minutes meeting.


Medical Record Creation

  • With established Patient Record Identification System

  • Maintain/Update a Standardized Patient Record for every patient assessed or treated

  • Duly accomplished consent form should accompany each patient's medical record

  • Authorized personnel to make entries in the medical record are clearly defined as per Hospital Policy

  • Abbreviations and symbols used in medical records are following WHO or approved by the health facility upon recommendation by the MRC

  • 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.

  • Assign ICD-10 codes to Diagnoses

  • Observe proper use of copy and paste function when electronic medical records are used

  • Check OPD and In-patient Records include all the necessary information based on the Standard

  • Patient record follows Standard Health record arrangement

  • Observe “ALERT” notation for conditions (i.e., allergic responses and adverse drug reactions) prominently displayed on the cover sheet.

  • Include the patient's past medical history and a sufficiently detailed report of a relevant Physical Examination (PE) completed within 24 hours upon admission

  • Reflect Therapeutic and Special diagnostic test orders

  • Record Progress Notes, observations, and consultation reports

  • 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

  • Check admission and discharge records use terminology based on the International Standard Nomenclature of Medicine

  • Discharge summary contains the following: Discharge diagnosis, Procedures performed, Follow-up arrangements, Therapeutic orders (home medications), and Patient home instructions

  • Certified true copy of the discharge summary is present when a patient is discharged or transferred to another facility

  • Autopsy report is filed when applicable, with provisional diagnosis noted within 72 hours

  • Incomplete patient records must be completed; diagnostic results must be submitted and attached to patient records

Medical Record Documentation

  • Completeness of patient records with no missing or detached form is present

  • Documents are legible and written in ink or typewritten

  • Written documents, including policies, procedures, and programs, are updated as necessary

  • MRD staff assists the attending physician in reviewing records for completeness

Medical Record Storage and Safekeeping

  • Inactive records are transferred to inactive filing storage to give way to the incoming records, decongest the area, and facilitate retrieval

  • MRD has a good and efficient retrieval system following policies and standards

  • The hospital safeguards all information contained in the patient record against loss, destruction, or unauthorized use

Medical Record Accessibility

  • All information in the patient record treated as confidential and disclosed only to authorized individuals

  • Release information with or without clinical value is done only with written consent/waiver from the patient

  • Hospital policy on releasing non-clinical information (name, address, attending physician, relative staying with patient during admission, admission, and discharge dates) is present

  • Updated policy on releasing patient records outside healthcare facilities and use for research and insurance providers is present

Medical Records Systems and Procedures

  • Policy on patient record identification system in place and implemented

  • Established proper assembly of patient records

  • Policy on the arrangement/structure/format of the content of patient records in place and implemented

  • Documentation guidelines implemented

  • Policy and procedures on the analysis of patient records, quantitative and qualitative analysis of patient records done in accordance to policies and procedures

  • Disease indexing correctly carried out

  • Policy/ procedure on the filing of patient records in place and implemented

  • Established proper filing and storage of patient records

  • Maintaining and updating Procedure on Retrieval of Patient records

  • Policy and Procedure on Retention and Disposal of Patient Records

ICD Coding

  • MRD staff trained on the latest ICD and clinical coding

  • Patient records conform with the latest ICD and clinical coding

Medico-Legal Aspects of Health Record

  • Consents and certificates properly filled out with complete and accurate clinical data before its intended use

  • Policy and procedure on handling telephone inquiries on demo data and clinical information

  • Policy and procedure on dealing with MRD clients requesting for patient's clinical information

Continuous Quality Improvement (CQI)

  • Trained staff on the development and implementation of CQI

  • Implements CQI for MRD

  • Conducted CBAHI Self-Assessment 2023?

  • What is the obtained score? Attach a copy of the total score of the self-assessment.

  • What are the sub-standards requiring corrective actions?

Risk Management

  • Trained staff on the development and implementation of Risk Management

  • Implements risk assessment and management for MRD

  • Please specify the identified risks related to Medical Records Department


  • Relevant reports prepared for use in the management process

  • What are the reports prepared?

  • Submission of timely and accurate report required by the TQM, MOH, and other agencies

INTERPRETATION OF SCORES 90 - 100% Excellence - Congratulations! 80 - 89% Quality - Congratulations for achieving quality service! Continue improving yourself. 60 - 79% Safety - Good effort! But we know that you can do better. Start planning your quality improvement. Below 60% Probationary - What can we do to help you? Please contact TQM Department.

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