________

OUR LADY OF CAYSASAY Document No.:

MEDICAL CENTER PHIC Bench Book Code:

Quality Policy Revision No.: 0

Effectivity Date: ________

Title: ACCURACY AND TIMELINESS OF MEDICAL RECORD Page 1 of 2

DOCUMENTATION

1. PURPOSE

Our Lady of Caysasay Medical center define general guidelines for documenting accuracy,
timeliness and completeness in the patient’s medical record.

2. SCOPE

Accuracy, timeliness is important even more so in some fields than others and attention to detail
are also essential characteristics for all health care workers. For example, if you are giving
medications, it is important that you give the correct medication to the correct patient at the right
time and then record the correct dose, time, route, and response. Timely documentation ensures
that the patient isn't given another dose. Always remember to treat team members as you would
like them to treat you. Don't impose unnecessarily.

3. POLICIES

3.1 Ensuring that all Medical Record entries are to be dated, the time entered, and printed name,
signed and designation of person recording the information.

3.2 In case, that we have a correction in the patient medical records, draw a single thin line and
put a date and initial to the top of corrections and put the correcting data.

3.3 Ensuring that the signatures should include the full name and their license number.

3.4 Verbal orders or telephone orders should authenticated their signed within the days of
duration. Or five days of duration.

3.5 Avoid use of abbreviations (other than those approved and documented in organizational
policy by the Medical Record Department)

3.6 Avoid duplication of patient information.

3.7 Identifies problems that have arisen and actions taken to rectify/address.

3.8 Records shall be retrieved base in our general policies of retrieval time.

3.9 systems for sharing information with others ensures only relevant information with relevant
others (also required to maintain confidentiality)

4. FORMS

Strictly confidential and not for use or disclosure outside Our Lady of Caysasay Medical Center Inc. except under written agreement.
Non-compliance to this SOPP shall be subject to sanctions as defined in the Company’s Code of Conduct.
 ________
OUR LADY OF CAYSASAY Document No.:

MEDICAL CENTER PHIC Bench Book Code:

Quality Policy Revision No.: 0

Effectivity Date: ________

Title: ACCURACY AND TIMELINESS OF MEDICAL RECORD Page 2 of 2

DOCUMENTATION

5. REPORTS

6. REVISION HISTORY

No revision was made as of this date.

Signed in Master Copy

Prepared By: Reviewed /Verified By: Approved By: Noted by:

Ms. Amorfina C. Hernandez Mr. Mark leo Mora Dr. Macrina Cheryl H. Valdez Dr. Margarito D. Hernandez
MR Officer HIS Director Hospital Administrator President / CEO

Ms. Whelyn B. Lascano Mr. Jerome Angelo H. Lascano

________________________ Quality Assurance SVP/ Chief Operations Officer ________________________
Date ________________________ Date
Date ________________________
Date

Strictly confidential and not for use or disclosure outside Our Lady of Caysasay Medical Center Inc. except under written agreement.
Non-compliance to this SOPP shall be subject to sanctions as defined in the Company’s Code of Conduct.