Assessment of Oncology Medical Records as per NABH Standards

Abstract

Background: A complete, accurate, adequate and timely medical documentation helps in reducing medical errors and serves as important medical–legal evidence.

Objective: To evaluate Oncology Medical Records based on the National Accreditation Board of Hospitals Information Management System (NABH.IMS) and Patient Rights and Education (NABH.PRE) standards.

Methods: This retrospective study was conducted to assess the policies and procedures in relation to medical documentation against NABH.IMS 1–7 standards and NABH.PRE-3 Standards. A total of 520 discharged inpatient records were analyzed to understand the quality of medical documentation in practice.

Results: The existing policies and procedures were found to be compliant with NABH.IMS and NABH.PRE standards. The analysis of medical records showed maximum compliance in Nurse’s records, Doctor’s order forms, Anaesthesia reports of Breast and Head & Neck Cancer and Radiotherapy Charts in Cervical Cancer.

Conclusion: Overall documentation was found to be satisfactory as per the standards set by NABH. The study results revealed that the attention to compulsorily document patient clinical data in the respective forms of the medical records will enhance the completeness and accuracy of medical documentation of the hospital.

Keywords

Medical documentation medical records Information Management System Patient Rights and Education compliance

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