NABH 6th Edition IMS Chapter: Information Management System Explained

What the IMS chapter is about

NABH's intent for IMS is that the right information reaches the right person at the right time. Information management includes the management information system (MIS), the hospital information system (HIS) and everything communicated to staff, patients, visitors and the community. Information must be authenticated, secure and accurate; confidentiality of protected health information is paramount on every platform; obsolete information is reviewed and withdrawn; and every patient has a complete and accurate medical record that is available to the people caring for them and reviewed at regular intervals.

Every Core element must score at least 4 out of 5 at every assessment. Our 6th Edition overview explains the scoring. NABH marks 11 IMS elements with an asterisk, meaning they must be documented: IMS.1.a, 1.b, 2.d, 3.b, 3.d, 5.a, 5.c, 5.f, 6.a, 6.b and 6.d.

The 7 standards at a glance

Information needs and IT (IMS.1–IMS.2)

The hospital identifies the information needs of patients, visitors, staff, management, external agencies and the community (IMS.1.a, Core) and captures or disseminates what is needed. IT purchases match those needs, the IT and communication network has a maintenance plan, and information resources are accurate (moved down from Excellence to Commitment). The hospital contributes to external databases as the law requires; the interpretation now gives the Materiovigilance Programme as an example. A contingency plan for information continuity (now with downtime monitoring) is an Achievement element, and using digital health technology to improve efficiency, safety and patient experience (IMS.1.h) is a new Excellence element.

IMS.2 asks for standardised data collection, analysis, timely and accurate dissemination, storage and retrieval, and involvement of clinical and managerial staff in choosing and using data.

Evidence that works: an information needs matrix (who needs what, from where, how often); an IT asset list with a maintenance plan; a HIS downtime procedure with paper backups; records of statutory reporting such as notifiable diseases and births and deaths.

A complete medical record (IMS.3)

Two Core elements anchor the record: every medical record has a unique identifier (IMS.3.a, raised from Commitment to Core in this edition), and the record gives a complete, up-to-date and chronological account of care (IMS.3.c). The contents of the record are defined (the interpretation now names nursing, dietary and physiotherapy assessments), only authorised staff make entries, every entry is signed, dated and timed, the author can be identified, and only authorised abbreviations are used.

Evidence that works: a medical records policy listing the contents of an in-patient file; a list of staff authorised to write in records; an approved abbreviations list, plus a do-not-use list; records where every note carries a name, signature, date and time.

Continuity of care in the record (IMS.4)

The record must contain the reasons for admission, diagnosis and care plan; assessments, reassessments and consultations; investigation results and the care given; operative and other procedures; transfer details when a patient goes to another hospital; a signed copy of the discharge summary (the interpretation now covers electronically signed records); and, after a death, a copy of the medical certificate of the cause of death with its details. Care providers must be able to see current and past records.

Confidentiality, integrity and security (IMS.5)

All three are Core: the hospital maintains the confidentiality (IMS.5.a), integrity (IMS.5.b) and security (IMS.5.c) of records, data and information. Privileged health information is disclosed only as the patient authorises or the law requires, and requests for access from patients, doctors and public agencies are handled consistently. Using appropriate technology to strengthen confidentiality, integrity and security is an Achievement element whose interpretation now includes risk assessment.

Evidence that works: a records room with restricted access; role-based HIS logins and audit trails; a policy on releasing records with a request register; backup and recovery tests; staff who know not to discuss patients in public areas.

Document control and retention (IMS.6)

An effective document control process (IMS.6.a, Core) keeps policies, forms and other documents current, with obsolete versions withdrawn; the interpretation now stresses that the system is implemented, not just written. Clinical records are retained according to the hospital's requirements (IMS.6.b, Core), with retention periods that should follow the National Medical Commission's rules (the interpretation replaced the old MCI reference) and any medico-legal requirements. Retention keeps records confidential and secure, and destruction follows written guidance.

Evidence that works: a master list of documents with version numbers and review dates; a retention schedule by record type; a destruction register with approvals.

Medical record review (IMS.7)

Records are reviewed periodically (IMS.7.a, Core; the interpretation now covers paper and electronic records). The review uses a statistically representative sample of both active and discharged patients' records, is done by identified people against identified parameters (a checklist is now expected), documents deficiencies and leads to corrective and preventive action. One of the 6th Edition's hospital-wide quality indicators is the percentage of medical records with incomplete or improper consent; see the NABH quality indicators list.

What changed from the 5th Edition

• Unique identifier for the medical record raised from Commitment to Core (IMS.3.a).
• New: use of digital health technology (IMS.1.h, Excellence).
• Accurate information resources (IMS.1.f) moved from Excellence to Commitment.
• Interpretations now cover IT downtime monitoring, materiovigilance reporting, nursing, dietary and physiotherapy assessments in the record, electronically signed records, cause-of-death details, risk assessment for information security, the National Medical Commission and a checklist for record review.

How assessors test IMS

Assessors pull files from the records room and from wards in use. They check that every page carries the patient's unique ID, that notes are signed, dated and timed, that abbreviations are on the approved list, and that the discharge summary is signed. They ask how a patient gets a copy of their records, who can log in to the HIS and what happens when it goes down, and they read your last record review to see whether its findings changed anything.

Getting IMS ready

1. Write the medical records policy: contents, authorised staff, abbreviations, access, retention and destruction.
2. Make sure every file and every HIS screen carries the unique identifier.
3. Set up document control with a master list and withdraw obsolete forms from every department.
4. Restrict access to physical records and HIS, and test your backups.
5. Start monthly record review with a checklist and feed the findings back to doctors and nurses.

Our NABH documents checklist lists the IMS policies, and we run 6th Edition gap analyses scored the way assessors score. Hospitals up to 50 beds follow the equivalent chapter in the SHCO standards.

All ten NABH 6th Edition chapter guides: AAC · COP · MOM · PRE · IPC · PSQ · ROM · FMS · HRM · IMS