medical records management (nabh)
Medical Records Management (NABH)
Trusted NABH-compliant management for patient data safety
Accuracy
Every record checked for precise details
Ensures complete patient health information
Reliable data for care and legal needs
Confidentiality
Accessibility
About Us
We provide NABH-compliant Medical Records Management services focused on accuracy, confidentiality, and regulatory compliance. Our processes ensure complete, legible, and timely documentation across all patient care areas. Through standardized formats, defined retention policies, and regular internal audits, we support hospitals in meeting NABH accreditation requirements, minimizing medico-legal risk, and improving documentation quality. We are committed to continuous improvement, data security, and audit readiness in healthcare information management.
Our Services
Reliable Medical records management to NABH standards
Electronic Medical Records (EMR) Support
We assist healthcare facilities in transitioning to and optimizing Electronic Medical Record systems.
Services include:
EMR data structuring & validation
Digital record workflows
Data accuracy & integrity checks
User training & documentation support
Medical Records Audit & Quality Improvement
Improve patient safety and hospital performance with structured medical record audits.
Services include:
Completeness & timeliness audits
Legal & medico-legal record checks
Quality indicator monitoring
Corrective & preventive action (CAPA) support
Healthcare Data Analytics & Reporting
Transform hospital data into meaningful insights using advanced analytics tools.
Services include:
Dashboard creation (Excel, Power BI)
MRD performance analytics
Patient flow & operational analysis
NABH indicator reporting
Medical Records checklist and quality indicators for NABH accreditation preparation
Medical Records of patient is the most important record that a hospital maintains. Contents in medical records serves as an important evidence of compliance to many NABH standards and objective elements. For a hospital that is preparing for NABH accreditation, concentrating on medical records is very important. Here is the list of things that must be ensured to comply with accreditation requirements.
(Please note that this checklist is meant for documentation and organizing of medical records and not meant for treatment audit or medical audit)
Checklist
Medical record of each patient should have a unique identification number.
Unique identification number of the medical record should be printed/written on every sheet inside the medical record to prevent misplacement of sheets.
If applicable, MLC identification and number and details should be mentioned on medical record.
Medical record should contain general consent of the patient in all admissions.
Medical records of currently admitted patients must contain documented initial assessment within the time-frame defined by hospital (maximum 24 hours). The documented initial assessment should include following:
a. Assessment of presenting complaints, vital signs (temperature, pulse, BP and respiration) and salient examination findings.
b. Specialty specific assessment findings.
c. Nursing assessment of patient and care plan (identification of nursing needs, special requirements of patients, identification of vulnerable patient etc.).
d. Nutritional screening to identify nutritional needs of patient, if any.
e. Diagnosis (Final or Provisional)
f. Plan of care, which includes treatment plan, preventive aspects of care and desired result of care.
Initial assessment record should have name, signature, date and time.
Plan of care should be signed / counter-signed by consultant in-charge of the patient.
Medical records should contain results of tests carried out, the care provided and re-assessment findings.
If patient is transferred to other hospital, medical records should contain date of transfer, reason of transfer and name of receiving hospital.
Each entry in medical records should be signed, named, dated and timed.
Entries in medical records should be legible.
Medication orders and charts should not have any non-standard abbreviations, or should have only those abbreviations that are defined by the hospital.
Entries in medical records should be up-to-date.
Medical records of patients who have undergone surgery should contain following documentation:
a. Pre-operative assessment
b. Type of anesthesia and anesthetic medications used
c. Safety checklist to prevent surgical errors (like WHO surgical safety checklist)
d. Informed consent (refer point no. 11 also)e. Operative note by the surgeon or his/her team member
f. Post-operative plan of care
15. Informed consent in medical records should contain following
a. Information on the surgical procedure, risks, benefits, alternatives, name of the doctor who will perform surgery
b. Informed consent should be in language that patient understands (having a bi-lingual consent form can be of help)
c. Consent form signed by patient (or guardian if applicable)
d. Consent form signed by the doctor taking consent
e. Consent form signed by an independent witness
16. Medical records of discharge patients should contain following documents
a. Discharge summary (refer point no. 14 also)
b. Death summary in case of deaths (should mention cause of death)
c. Final diagnosis of the patient
d. ICD coding on the file within a defined timeframe
e. In case of autopsy, copy of autopsy report
17. Discharge summary of patient should contain following documentation
a. Patient’s name, demographic details and unique identification number
b. Date of admission and date of discharge
c. Reason of admission, significant findings, diagnosis and patient’s condition at the time of discharge
d. Information regarding investigation results, any procedure performed, medication administered and other treatment given
e. Follow-up advice, medication and other instructions
f. Instruction on when to obtain urgent care
g. Instruction on how to obtain urgent care
18. Safety, security and confidentiality of medical records
Medical records department should additionally take care of following points:
a. Sufficient and safe storage for medical records
b. Regular pest control in medical record storage area
c. Availability of fire extinguisher nearby and knowledge on how to use the same
d. Policy of who can access medical records
e. How to respond to different requests for accessing medical records
f. Mechanism to quickly retrieve the medical records
g. ICD codification
h. Screening of medical records
Quality Indicators – Medical Records
Percentage of medical records in which plan of care is documented and countersigned
Percentage of medical records in which nursing care plan is documented
Percentage of medication charts with error-prone abbreviations
Percentage of medical records not having ICD codes
Percentage of medical records not having discharge summary
Percentage of medical records having incomplete / improper consent
Percentage of missing medical records
Medical Records Management (MRD)
We provide end-to-end medical records management solutions to ensure accurate, complete, and well-maintained patient records in line with hospital policies and regulatory requirements.
Services include:
Patient file organization & indexing
OPD & IPD medical record maintenance
Record retention & retrieval systems
Confidentiality & data security management
NABH Documentation & Compliance Support
We help hospitals achieve and maintain NABH compliance through structured documentation, audits, and standard operating procedures (SOPs).
Services include:
NABH medical records gap analysis
SOPs & policy documentation
Record-keeping standards implementation
Pre-assessment & internal audits
Medical Coding & Clinical Documentation
Accurate coding and documentation are essential for quality reporting and compliance.
Services include:
ICD-10 & clinical coding support
Documentation accuracy checks
Discharge summary standardization
Coding audit & error reduction
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