Evaluate medical record-keeping, quality, content, format, accuracy, pertinence, staff compliance with documentation policies. Review and evaluate fatal cases/ Deaths in hospital. Frequency of meeting: Quarterly/ as required

Scope

Applicable to all the members in the medical record review committee.

Constitution of the committee

• Manager Administration Quality & Nursing Chairperson
• Manager Quality & Operations –Member
• MRD HOD
• MRD in-charge Secretary
• MRD staff Member
• MRD clerk – Member

The chairman shall have the authority to invite any non-member to attend the meeting, if it is deemed fit in relation to any matter being/ or to be deliberated by the committee.

Quorum

The minimum quorum for passing any resolution in the committee should be 50% of the members present in the committee with chairperson being mandatory.

Frequency of meeting

Members of the committee meet once in three months.

Selection of members

1. Chairperson Selected by the chairman of Apex Committee
2. Secretary Selected by the chairperson, he or she is also a member of the committee
3. Members Selected by the chairperson

Responsibilities

• To discuss and take decision on any issues related with medical record department and any related processes
• To review the completeness of the patient’s records in the Medical Record.
• To see that all records are dated, timed and legibly signed by the persons authorized to make entries in patient’s records.
• To review that the patients record contains all the necessary documents ( as applicable)
• To identify any discrepancy in the records such as absence of date, time or signature, lack of proper documentation or incomplete record etc.
• To instruct the medical record department to rectify the deficiency on an immediate basis.
• To provide guideline instruction for better management of patient’s medical records
• The minutes of the meeting are recorded in the minutes in order to trace the points discussed in the meeting, decisions taken, discrepancy if any in patient’s record noted, remedial measures suggested, actions taken etc.
• In case the committee issues any sort of instruction relating to the patients record, the progress on the same is reviewed at the next meeting.

Role of chairperson

• Acts as a liaison between the medical record review committee members and the hospital administration.
• Receives all the audit reports and information pertaining to MRD, initiate necessary action based on the reports.
• Keep oneself abreast with the recent developments in the field.

Role of secretary (Member secretary)

• Prepare the agenda for the next meeting
• Submission for approval of agenda by the chairperson
• Inform the committee members regarding the next meeting at least 2 days before the meeting
• The minutes of meeting shall be prepared by the secretary
• Get the approval of minutes by the chairperson
• Circulate the agenda approved by the chair person to the members and the concerned persons
• To maintain all records ( as per list) related to the committee
• Submission of a copy of the agenda and the minutes of the meeting to the quality department after getting signature from all the concerned members

Agenda

Agendas for the meeting shall be prepared by the secretary in consultation with the chair person and signed by the chair. Then it is sent to all committee members and other experts. The agenda shall be sent to all at least 2 days before the scheduled meeting.

A meeting shall be called even by an oral / telephone communication in case of an emergency meeting. A justification for the emergency meeting has to be given.

Minutes

• Shall be prepared by secretary.
• MoM is send to the chairperson for the approval within three days of the meeting.
• After the approval of the minutes by the chairperson, the approved minutes are circulated within 2 days of the meeting to all the committee members and the person concerned for implementation.
• A copy of the agenda and minutes of every meeting shall be sent to the quality manager by the member secretary

Decision making

• A thorough discussion of the agenda shall be done by the committee members and based on their suggestion and recommendations the issue shall be weighed. Also as and when needed any kind of trial study may be performed and based on the outcome of it the committee will decide on that issue.
• The decision of the committee will be finally taken by a majority vote and that shall be implemented.

Records to be maintained

• List and details of all members
• The TOR of the committee
• Copy of all agendas, minutes of all meeting
• Attendance sheet
• Copy of any other correspondence to the committee members or non-members
• Copy of any study conducted for the sake of the committee