Self Assessment Toolkit

Organisation is required to provide self assessment report in the format 'Self Assessment Toolkit' given below. All the entries are to be properly filled
up. Regarding scoring following criteria would be applicable.

Compliance to the requirement: 10

Partial compliance to the requirement: 5 (if any of the sample is found to be noncomplying out of total samples selected)
Non-compliance to the requirement: 0
Not Applicable: NA

Evaluation Criteria during final assessment:

· No individual standard should have more than one zero to qualify. However, no zero is accepted in the regulatory/ legal requirements.
· The average score for individual standard must not be less than 5.
· The average score for individual chapter must not be less than 7.
· The overall average score for all standards must exceed 7.

Special Note:
Self assessments should be done by the hospital in a stringent manner and if at the time of Pre assessment it is found that
there is a significant difference between the self assessment and the pre assessment report then organisations can apply for
final assessment not earlier than six months from the date of completion of Pre assessment.

(Name & Address of the Hospital)

 SELF ASSESSMENT TOOLKIT
Evidence
Documentation Implementation (cross reference to Scores
Elements
(Yes/ No) (Yes/ No) documents/ (0/ 5/ 10)
manuals etc.)

Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF

CARE (AAC)
AAC.1: The organization defines and displays the services that it can provide.
a The services being provided are clearly defined.

b The defined services are prominently displayed.

c The staff is oriented to these services.

AAC.2: The organization has a documented registration, admission and

transfer process.
a. Process addresses registering and admitting out-patients, in-patients and
emergency patients.
b. Process addresses managing patients during non availability of beds.

c. Patients are accepted only if the organization can provide the required service.

d. Process addresses mechanism for transfer or referral of patients who do not

match the organizational resources.

AAC.3 Patients cared for by the organization undergo an established initial

assessment.
a. The organization defines the content of the assessments for the out-patients, in-
patients and emergency patients.
b. The organization determines who can perform the assessments.
 c. The organization defines the time frame within which the initial assessment is
completed.
d. The initial assessment for in-patients is documented within 24 hours or earlier.

AAC.4 Patient care is continuous and all patients cared for by the
organization undergo a regular reassessment.
a. During all phases of care, there is a qualified individual identified as responsible
for the patient’s care who coordinates the care in all the settings within the
organization.
b. All patients are reassessed at appropriate intervals.

c. Staff involved in direct clinical care document reassessments.

d. Patients are reassessed to determine their response to treatment and to plan

further treatment or discharge.
AAC.5 Laboratory services are provided as per the scope of the hospital’s
services and adhering to best practices.
a. Scope of the laboratory services are commensurate to the services provided by
the organization.
b. Adequately qualified and trained personnel perform and/ or supervise the
investigations.
c. Procedures guide collection, identification, handling, safe transportation,
processing and disposal of specimens.
d. Laboratory results are available within a defined time frame and critical results are
intimated immediately to the concerned personnel.
e. Laboratory tests not available in the organization are outsourced to
organization(s) based on their quality assurance system.
f. Laboratory personnel are trained in safe practices and are provided with
appropriate safety equipment/ devices.
g. Quality assurance for laboratory should be as per accepted practices and also
include periodic calibration and maintenance of all equipments.
AAC.6 Imaging services are provided as per the scope of the hospital’s
services and adhering to best practices.
 a. Imaging services comply with legal and other requirements.

b. Scope of the imaging services are commensurate to the services provided by the
organization.
c. Adequately qualified and trained personnel perform, supervise and interpret the
investigations.
d. Imaging results are available within a defined time frame and critical results are
intimated immediately to the concerned personnel.
e. Imaging tests not available in the organization are outsourced to organization(s)
based on their quality assurance system.
f. Imaging personnel are trained in safe practices and are provided with appropriate
safety equipment/ devices.
g. Quality assurance for Radiology services should be as per accepted practices
and also include periodic calibration and maintenance of all equipments.

AAC.7 The organisation has a defined discharge process.

a. Process addresses discharge of all patients including Medico-legal cases and

patients leaving against medical advice.
b. A discharge summary is given to all the patients leaving the organization
(including patients leaving against medical advice).
c. Discharge summary contains the reasons for admission, significant findings,
investigation results, diagnosis, procedure performed (if any), treatment given and
the patient’s condition at the time of discharge.

d. Discharge summary contains follow up advice, medication and other instructions

in an understandable manner.
e. Discharge summary incorporates instructions about when and how to obtain
urgent care.
f. In case of death the summary of the case also includes the cause of death.

Chapter 2: CARE OF PATIENTS (COP)

COP.1: Care of patients is uniform and is guided by established standards &
guidelines
a Care delivery is uniform when similar care is provided in more than one setting.

b Care delivery includes special needs of vulnerable patients (elderly, children,

physically and/ or mentally challenged).
c The care and treatment orders are signed, named, timed and dated by the
concerned doctor.
d The care plan is countersigned by the clinician in-charge of the patient within 24
hours.
e Evidence based medicine and clinical practice guidelines are adopted to guide
patient care whenever possible.

COP2: Emergency services including ambulance are guided by documented

procedures and applicable laws and regulations
a Documented procedures address care of patients arriving in the emergency
including handling of medico-legal cases.
b Documented procedures also guides the triage of patients for initiation of
appropriate care.
c Staff is trained on the procedures for care of emergency patients.

d Admission or discharge to home or transfer to another organization is also

documented.
e Ambulance is appropriately equipped and manned by trained personnel.

f In the ambulance, there is a checklist of all equipment and emergency

medications which is checked on a regular basis.

COP.3: Documented procedures guide the care of patients requiring cardio-

pulmonary resuscitation.
a Documented procedures guide the uniform use of resuscitation throughout the
organization.
b Staff providing direct patient care is trained and periodically updated in cardio-
pulmonary resuscitation.
c Events during cardio-pulmonary resuscitation are recorded.
COP.4: Documented procedures define rational use of blood and blood
products.
a The blood bank services are governed by the applicable laws and regulations.

b Informed consent is obtained for donation and transfusion of blood and blood
products.
c Procedure addresses documenting and reporting of transfusion reactions.

COP.5: Documented procedures guide the care of patients in the Intensive

care and high dependency units.
a The organization has documented admission and discharge criteria for its
intensive care and high dependency units.
b Care of patients is in consonance with the documented procedures.

c Adequate staff and equipment are available.

COP.6: Documented procedures guide the care of obstetrical patients.

a The organization defines the scope of obstetric services.

b Obstetric patient’s care includes regular ante-natal check ups, maternal nutrition
and post-natal care.
c The organization has the facilities to take care of neonates.

COP.7: Documented procedures guide the care of pediatric patients.

a The organization defines the scope of its pediatric services.

b Provisions are made for special care of children by competent staff.

c Patient assessment includes detailed nutritional, growth, and immunization

assessment.
d Procedure addresses prevention of child/ neonate abduction and abuse.
 e The children’s family members are educated about nutrition, immunization and
safe parenting.
COP.8: Documented procedures guide the care of patients undergoing
parenteral sedation.
a The person administering and monitoring sedation is different from the person
performing the procedure.
b Patient’s vital parameters are monitored during and after sedation and are
discharged/ transferred once they are stable.
c Equipment and manpower are available to rescue patients from a deeper level of
sedation than that intended.

COP.9: Documented procedures guide the administration of anesthesia.

a. There is a documented procedure for the administration of anesthesia.

b. All patients for anesthesia have a pre-anesthesia assessment by a qualified

individual.
c. The pre-anesthesia assessment results in formulation of an anesthesia plan
which is documented.
d. An immediate preoperative re-evaluation is documented.

e. Informed consent for administration of anesthesia is obtained by the anesthetist.

f. Anesthesia monitoring includes regular and periodic recording of heart rate,

cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway
security and patency and level of anesthesia.
g. Each patient’s post-anesthesia status is monitored and documented.

h. A qualified individual applies defined criteria to transfer the patient from the
recovery area.
i. All adverse anesthesia events are recorded and monitored.

COP.10: Documented procedure guide the care of patients undergoing

surgical procedures.
 a. Surgical patients have a preoperative assessment and a provisional diagnosis
documented prior to surgery.
b. An informed consent is obtained by a surgeon prior to the procedure.

c. The documented procedure addresses the prevention of adverse events like

wrong site, wrong patient and wrong surgery.
d. Persons qualified by law are permitted to perform the procedures that they are
entitled to perform.
e. A brief operative note is documented prior to transfer out of patient from recovery
area.
f. The operating surgeon documents the post-operative plan of care.

g. The operation theatre is adequately spaced, equipped and monitored for infection
control practices.

Chapter 3: MANAGEMENT OF MEDICATION (MOM)

MOM.1: Documented procedures guide the organization of pharmacy
services and usage of medication.
a Documented procedure shall incorporate purchase, storage, prescription and
dispensation of medications.
b These comply with the applicable laws and regulations.

c The hospital has a list of medications appropriate for the patient’s and
organization’s resources.
d Sound alike and look alike medications are stored separately.

e Beyond expiry date medications are not stored/ used.

f Documented procedures address procurement and usage of implantable

prostheses.

MOM.2: Documented procedure guide the prescription of medications.

a The organization determines who can write orders.
 b Orders are written in a uniform location in the medical records.

c Medication orders are clear, legible, dated, named and signed.

d Procedure addresses verbal orders and is implemented.

e The organization defines a list of high risk medication.

MOM.3: Policies & procedure guide the safe dispensing of medications.

a This includes a procedure for medication recall.

b Medications are checked prior to dispensing, including the expiry date to ensure
that they are fit for use.
c High risk medication orders are verified prior to dispensing.

MOM.4: There are defined procedures for medication administration.

a Medications are administered by those who are permitted by law to do so.

b Patient is identified prior to administration.

c Prior to administration medication order including dosage, route and timing are
verified.
d Prepared medication is labelled prior to preparation of a second drug.

e Medication administration is documented.

f A proper record is kept of the usage, administration and disposal of narcotics and
psychotropic medications.
g The procedure addresses patient’s self administration of medications and
medications brought from outside the organization.

MOM.5: Patients are monitored for adverse drug events after medication
administration.
a Adverse drug events are defined.
 b Adverse drug events are documented and reported within a specified time frame.

c Adverse drug events are collected, analyzed by the treating doctor and practices
are modified (if necessary) to reduce the same.

MOM.6: Documented procedures guide the use of medical gases.

a Documented procedures govern procurement, handling, storage, distribution,
usage and replenishment of medical gases.

b Procedures address the safety issues at all levels.

c Appropriate records are maintained in accordance with policies, procedures and

legal requirements.

Chapter 4: PATIENT RIGHTS AND EDUCATION (PRE)

PRE.1: The organization protects patient and family rights during care and
informs them about their responsibilities.
a Patient and family rights and responsibilities are documented.

b Patients and families are informed of their rights and responsibilities in a format
and language that they can understand.
c Staff is aware of their responsibility in protecting patients and family rights.

d Violation of patient and family rights is recorded, reviewed and corrective/

preventive measures taken by the organization’s leaders.
PRE.2: Patient rights support individual beliefs, values and involve the
patient and family in decision making processes.
a Patient rights include respect for personal dignity and privacy during examination,
procedures and treatment.
b Patient rights include protection from physical abuse or neglect.

c Patient rights include treating patient information as confidential.

d Patient rights include refusal of treatment.

 e Patient rights include obtaining informed consent before carrying out procedures.

f Patient rights include information and consent before any research protocol is
initiated.
g Patient rights include information on how to voice a complaint.

h. Patient rights include information on the expected cost of the treatment.

i. Patient has a right to have an access to his/ her clinical records.

PRE.3: A documented policy for obtaining patient and/ or families consent

exists for informed decision making about their care.
a General consent for treatment is obtained when the patient enters the
organization.
b Patient and/ or his family members are informed of the scope of such general
consent.
c The organization has listed those situations where informed consent is required
as per national guidelines.
d Informed consent includes information on risks, benefits, alternatives and as to
who will perform the requisite procedure in a language that they can understand.

e The policy describes who can give consent when patient is incapable of
independent decision making.

PRE.4: Patient and families have a right to information and education about
their healthcare needs.
a Patients and families are educated to make informed decisions pertaining to plan
of care, preventive aspects, possible complications, the expected results and
costs at the time of admission.
b When appropriate, patient and families are educated about the safe and effective
use of medication and the potential side effects of the medication.
c Patient and families are educated about diet and nutrition.

d Patient and families are educated about immunization.

 e Patient and families are educated about preventing infections.

f Patients are taught in a language and format that they can understand.

PRE.5: Patient and families have a right to information on expected costs.

a There is uniform pricing policy in a given setting (out-patient and ward category).

b The tariff list is available to patients.

c Patients are educated about the estimated costs of treatment.

d Patients are informed about the financial implications when there is a change in
the patient condition or treatment setting.

Chapter 5: HOSPITAL INFECTION CONTROL (HIC)

HIC.1: The organization has a well-designed, comprehensive and coordinated
Hospital Infection Control (HIC) programme aimed at reducing/ eliminating
risks to patients, visitors and providers of care.
a The hospital has an infection control committee.

b The hospital has a designated individual for infection control activities.

c The hospital infection control programme is documented.

HIC.2: The hospital has an infection control manual, which is periodically

updated and conducts surveillance activities.
a The manual identifies the various high-risk areas.

b It outlines methods of surveillance in the identified high-risk areas.

c Surveillance activities are appropriately directed towards the identified high-risk

areas.
d It focuses on adherence to standard precautions at all times.
 e Equipment cleaning and sterilisation practices are included.

f Laundry and linen management processes are also included.

g Kitchen sanitation and food handling issues are included in the manual.

h Engineering controls to prevent infections are included.

i Scope of surveillance activities incorporates tracking and analyzing appropriate

infection rates.
j Feedbacks regarding these rates are provided on a regular basis to medical and
nursing staff.

HIC.3: The hospital takes actions to prevent or reduce the risks of Hospital
Associated Infections (HAI) in patients and employees.
a Hand washing facilities in all patient care areas are accessible to health care
providers.
b Compliance with proper hand washing is monitored regularly.

c Isolation/ barrier nursing facilities are available.

d Adequate gloves, masks, soaps, and disinfectants are available and used
correctly.
e Appropriate pre and post exposure prophylaxis is provided to all concerned staff
members.

HIC.4: There are documented procedures for sterilisation activities in the

hospital.

a There is adequate space available for sterilization activities.

b Regular validation tests for sterilisation are carried out and documented.

c There is an established recall procedure when breakdown in the sterilisation

system is identified.
HIC.5: Statutory provisions with regard to Bio-Medical Waste (BMW)
management are complied with.
 a The hospital is authorised by prescribed authority for the management and
handling of Bio-Medical Waste.
b Proper segregation and collection of Bio-Medical Waste from all patient care
areas of the hospital is implemented and monitored.
c The organization ensures that Bio-Medical Waste is stored and transported to the
site of treatment and disposal in proper covered vehicles within stipulated time
limits in a secure manner.
d Bio-Medical Waste treatment facility is managed as per statutory provisions (if in-
house) or outsourced to authorised contractor(s).
e Requisite fees, documents and reports are submitted to competent authorities on
stipulated dates.
f Appropriate personal protective measures are used by all categories of staff
handling Bio-Medical Waste.

HIC.6: The infection control programme is supported by hospital

management and includes training of staff and employee health.
a Hospital management makes available resources required for the infection control
programme.
b It conducts regular pre-induction training for appropriate categories of staff before
joining concerned department(s).
c It also conducts regular ‘in-service’ training sessions for all concerned categories
of staff at least once in a year.

Chapter 6: CONTINUOUS QUALITY IMPROVEMENT (CQI)

CQI.1: There is a structured quality improvement and continuous monitoring
programme in the organization.
a The organization develops, implements, maintains and document quality
improvement programme.
b There is a designated individual for coordinating and implementing the quality
improvement programme.
c The quality improvement programme is comprehensive and covers all the major
elements related to quality improvement and risk management.
 d The designated programme is communicated and coordinated amongst all the
employees of the organization through proper training mechanism.

e The quality improvement programme is reviewed at predefined intervals and

opportunities for improvement are identified.
f The quality improvement programme is a continuous process and updated at
least once in a year.

CQI.2: The organization identifies key indicators to monitor the structures,

processes and outcomes which are used as tools for continual improvement.

a Organization shall identify the appropriate key performance indicators in both

clinical and managerial areas.
b Indicators shall be related to structures, processes and outcomes.

c These indicators shall be monitored.

d Monitoring includes performance of quality improvement activities in diagnostics,

ICUs and operation theatres.
e Monitoring includes patient satisfaction which also incorporates waiting time for
services.
f Monitoring includes employee satisfaction.

g Monitoring includes safety aspects including adverse events.

h Data collected are used as tools for further improvements

i Monitoring includes data collection to support evaluation of these improvements.

CQI.3: The quality improvement programme is supported by the

management.
a Hospital Management makes available adequate resources required for quality
improvement programme.
b Appropriate statistical and management tools are applied whenever required.
CQI.4: There is an established system for clinical audits.
a Medical staff participates in this system.

b The parameters to be audited are defined by the organisation.

c Patient and staff anonymity is maintained.

d All audits are documented.

e Remedial measures are implemented.

CQI5: Sentinel events are intensively analyzed

a The organization has identified the appropriate sentinel events.

b The organisation has established processes for intense analysis of such events
when they occur.

c Corrective and Preventive Actions are taken based on the findings of such
analysis.

Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM)

ROM.1: The responsibilities of the management are defined.

a The organization has a documented organogram.

b Those responsible for management support quality improvement plans.

c The management defines the rights and responsibilities of employees.

d The organization is registered with appropriate authorities as applicable.

e Those responsible for management address the organization’s social

responsibility.
ROM.2: The organization is managed by the leaders in an ethical manner.
a The management makes public the mission statement of the organization.

b The leaders establish the organization’s ethical management.

c The organization discloses its ownership.

d The organization honestly portrays the services which it can provide.

e The organization honestly portrays its affiliations and accreditations.

f The organization accurately bills for its services based upon a billing tariff.

ROM.3: Leaders ensure that patient safety aspects and risk management
issues are an integral part of patient care and hospital management.

a The organization has a designated individual(s) to oversee the hospital wide

safety programme.
b The scope of the programme is defined to include adverse events ranging from
‘no harm’ to ‘sentinel events’.
c Management ensures internal and external reporting of system and process
failures.

Chapter 8: FACILITY MANAGEMENT AND SAFETY (FMS)

FMS.1: The organization’s environment and facilities operate to ensure safety
of patients, their families, staff and visitors.
a There is a documented operational and maintenance (preventive and breakdown)
plan.
b Up-to-date drawings are maintained which detail the site layout, floor plans and
fire escape routes.
c The provision of space shall be in accordance with the available literature on good
practices.
 d Maintenance staff is contactable round the clock for emergency repairs.

e The hospital has a system to identify the potential safety and security risks
including hazardous materials.
f Facility inspection rounds to ensure safety are conducted periodically.

g There is a safety education programme for all staff.

FMS.2: The organization has a program for clinical and support service
equipment management.
a The organization plans for equipment in accordance with its services.

b All equipment is inventoried and proper logs are maintained as required.

c Qualified and trained personnel operate and maintain the equipment.

d Equipment are periodically inspected and calibrated for their proper functioning.

e There is a documented operational and maintenance (preventive and breakdown)

plan.
FMS.3: The organization has provisions for safe water, electricity, medical
gas and vacuum systems.
a Potable water and electricity are available round the clock.

b Alternate sources are provided for in case of failure and tested regularly.

c There is a maintenance plan for medical gas and vacuum systems.

FMS.4: The organization has plans for fire and non-fire emergencies within
the facilities.
a The organization has plans and provisions for early detection, abatement and
containment of fire and non-fire emergencies.
b The organization has a documented safe exit plan in case of fire and non-fire
emergencies.
 c Staff is trained for their role in case of such emergencies.

d Mock drills are held at least twice in a year.

Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM)

HRM.1: The organization has a documented system of human resource
planning.
a The organization plans and maintains an adequate number and mix of staff to
meet the care, treatment and service needs of the patient.

b The organization verifies the antecedents of the potential employee.

HRM.2: The staff joining the organization is socialized and oriented to the
hospital environment.
a Each staff member is appropriately oriented to the organization’s mission, policies
and procedures.
b Each staff member is made aware of his/her rights and responsibilities.

c All employees are educated with regard to patients’ rights and responsibilities.

HRM.3: There is an ongoing programme for professional training and

development of the staff.
a A documented training and development policy exists for the staff.

b All staff is trained on the risks within the hospital environment.

c Staff members can demonstrate and take actions to report, eliminate/ minimize
risks.
d Training also occurs when job responsibilities change/ new equipment is
introduced.
e Feedback mechanisms for assessment of training and development programme
exist.
HRM.4: An appraisal system for evaluating the performance of an employee
exists as an integral part of the human resource management process.

a The appraisal system is documented.

b All employees are aware of the system of appraisal.

c Performance is evaluated based on pre-defined criteria which the employee is

aware of.
d Performance appraisal is carried out at pre defined intervals and is documented

HRM.5: The organization has a well-documented disciplinary and grievance

handling procedure.
a A documented procedure with regard to these is in place.

b The documented procedure is known to all categories of employees in the

organization.
c The disciplinary procedure is in consonance with the prevailing laws.

d The redress procedure addresses the grievance.

e Actions are taken to redress the grievance.

HRM.6: The organization addresses the health needs of the employees.

a Health problems of the employees are taken care of in accordance with the
organization’s policy.
b Occupational health hazards are adequately addressed.

HRM.7: There is a documented personal record for each staff member.

 a Personal files are maintained in respect of all employees.

b The personal files contain personal information regarding the employees

qualification, disciplinary background and health status.
c All records of in-service training and education are contained in the personal files.

d Personal files contain results of all evaluations.

HRM.8: There is a process for authorising all medical professionals to admit

and treat patients and provide other clinical services commensurate with
their qualifications.
a Medical professionals permitted by law, regulation and the hospital to provide
patient care without supervision are appointed.
b Medical professionals admit and care for patients as per the laid down policies
and authorisation procedures of the organization.
c The services provided by the medical professionals are in consonance with their
qualification, training and registration.

HRM.9: There is a process to identify job responsibilities and make clinical

work assignments to all nursing staff members commensurate with their
qualifications and any other regulatory requirements.
a The clinical work assigned to nursing staff is in consonance with their qualification,
training and registration.
b The services provided by nursing staff are in accordance with the prevailing laws
and regulations.

Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS)

IMS.1: Documented procedures exist for effective information management to

meet the information needs of the care providers, management of the
organization as well as external agencies that require data and information
from the organization.
a A documented procedure exists to meet the information needs.
 b Formats for data collection are standardized.

c Necessary resources are available for analyzing data.

d Documented procedures are laid down for timely and accurate dissemination of
data.
e Documented procedures exist for storing and retrieving data.

f The organization contributes to external databases in accordance with the law

and regulations.
IMS.2: The organization has a complete and accurate medical record for
every patient.
a Every medical record has a unique identifier.

b Organisation 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 are identified and documented.

IMS.3:The medical record reflects continuity of care

a The record provides an up-to-date and chronological account of patient care.

b The medical record contains information regarding reasons for admission,

diagnosis and plan of care.
c Operative and other procedures performed are incorporated in the medical
record.
d When patient is transferred to another hospital, the medical record contains the
date of transfer, the reason for the transfer and the name of the receiving hospital.

e The medical record contains a copy of the discharge note duly signed by
appropriate and qualified personnel.
 f In case of death, the medical record contains a copy of the death certificate
indicating the cause, date and time of death.
g Whenever a clinical autopsy is carried out, the medical record contains a copy of
the report of the same.
h Care providers have access to current and past medical record.

IMS.4: Documented procedures are in place for maintaining confidentiality,

integrity and security of information.
a Documented procedures exist for maintaining confidentiality, security and integrity
of information.
b Documented procedures are in consonance with the applicable laws.

c Documented procedures incorporate safeguarding of data/ record against loss,

destruction and tampering.
d Privileged health information is used for the purposes identified or as required by
law and not disclosed without the patient’s authorization.
e A documented procedure exists on how to respond to patients/ physicians and
other public agencies requests for access to information in the medical record in
accordance with the local and national law.

IMS.5: Documented procedures exist for retention time of records, data and
information.
a Documented procedures are in place on retaining the patient’s clinical records,
data and information.
b The procedures are in consonance with the local and national laws and
regulations.
c The retention process provides expected confidentiality and security.

d The destruction of medical records, data and information is in accordance with the
laid down procedure.

IMS.6: The organization regularly carries out review of medical records audit.

a The medical records are reviewed periodically.

b The review uses a representative sample based on statistical principles.

c The review is conducted by identified care providers.

d The review focuses on the timeliness, legibility and completeness of the medical
records
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.