MOI.1. The DC has a policy that defines what information is shared with staff (internal) and with other governmental and non-governmental entities (external).
MOI.1.1. The policy defines how patient demographics and medical information is shared among medical and administrative staff (paper format, electronic, or a combination).
MOI.1.2. The policy identifies how information is dispersed from staff to leaders and conversely from the leadership to staff.
MOI.1.3. The policy define what information is required to be reported to the Ministry of Health and the frequency of reporting.
MOI.1.4. The policy defines what patient information, personal and medical, that is required to be referred to a higher center.
MOI.1.5. The policy identifies the staff security levels for accessing patient information.
MOI.1.6. The policy identifies how all types of information are secured and safely stored.
MOI.1.7. The policy highlights how long the DC is required to store the various types of information (records retention) as consistent with the MOH rules and regulations.
MOI.2. The DC uses standardized diagnosis codes, procedure codes, symbols and minimizes abbreviations.
MOI.2.1. The DC uses diagnosis and procedure codes consistent with the MOH requirements.
MOI.2.2. The DC has a limited list of abbreviations and symbols distributed in all patient care areas for reference.
MOI.3. All patients seen in the DC have unique medical record files.
MOI.3.1. The contents of the medical record are arranged according to a standardized process.
MOI.3.2. Medical record files contain the required patient demographics, including National identification, contact information, emergency contacts, and insurance information.
MOI.3.3. Medical/ record files contain sufficient updated medical information to safely manage the patient (history and physical examination, plan of care, investigations, consultations, observations, consents, procedure/surgery reports, and medications) and promote continuity of care.
MOI.3.4. Medical records contain information related to adverse events and unanticipated incidents.
MOI.3.5. Patient allergies, prior adverse reactions, anticoagulation medications, and chronic infections are confidentially documented and consistently displayed in a specified area of the patient's record.
MOI.4. The DC has a policy on rules and regulations for writing in medical record files.
MOI.4.1. The medical records policy identifies the category of staff allowed to write in the medical record.
MOI.4.2. All entries in the patient's medical record are legible, dated, timed, and signed by the author.
MOI.4.3. There is uniform entry of data in medical records, whereby orders are written separately from assessments, care plans, and progress notes.
MOI.4.4. Entries written in error in the medical record are not deleted or erased. Instead, a line is passed through the error text and the entry is dated, timed, and signed by the author.
MOI.4.5. Only standardized and approved abbreviations and symbols are used in medical records.
MOI.5. The DC has a process for completing and storing patient medical record files.
MOI.5.1. The DC has a dedicated and secured storage method/area for all medical record files.
MOI.5.2. Regular checks are made on returned files to ensure completion (demographics, medical information, and authentication).
MOI.5.3. Noncompleted files are separated from completed ones in the storage area. They are completed in a time frame defined by the service.
MOI.5.4. The DC keeps a record for the percentage of incomplete records over time and uses this information to improve staff compliance with record completion.
MOI.6. The DC develops a policy and procedure for the use of information technology.
MOI.6.1. The policy and procedure on information technology highlights how generated information is stored and regularly backed up.
MOI.6.2. The policy and procedure describe the manual procedures required capture and record data in the event of system failure, maintenance, or repair.
MOI.6.3. Staff can demonstrate the manual procedure to be used in the event of system failure, maintenance or repair.
MOI.7. The leaders ensure the integrity and security of telemedicine, teleradiology, and interpretation of other diagnostic remote contracted services.
MOI.7.1. Telemedicine, teleradiology, and interpretation of other diagnostic remote contracted services are registered and comply with national health rules and regulations.
MOI.7.2. The leaders ensure the credentialing and privileging of all healthcare providers involved in the process of providing diagnostic remote services before starting the service.
MOI.7.3. The leaders ensure the security and confidentiality of patient information exposed because of the telecommunication process.
MOI.8. The DC implements an effective clinical documentation improvement (CDI) program.
MOI.8.1. The DC develops a policy and procedure for the clinical documentation improvement program.
MOI.8.2. The DC has, at a minimum, a physician and a nurse who are adequately trained on clinical documentation improvement.