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9.0  Documentation and Archiving Plans

The policies and procedures outlined in the Documentation and Archiving Plans shall be followed with adjustments when indicated.

Documentation and Archiving of Maternal Death Control Management System

Documentation and Archiving Blueprint

1. Documentation is the process or procedure in furnishing material or record that provides official information or evidence of activities that transpired.

2. Archiving is the process or procedure in preserving documents and records.

3. There shall be a documented documentation policies and procedures on the Maternal Death Control Management System.

4. The documented documentation policies and procedures must be aligned and integrated with those of the hospital / medical center.

5. There shall be a documented archiving policies and procedures on the documents and records of the Maternal Death Control Management System.

6. The documented archiving policies and procedures must be aligned and integrated with those of the hospital or medical center.

Documentation

7. There shall documentation of all activities of the Maternal Death Control Management System, both formal and informal.  Examples of formal activities are patient medical recording; strategic planning conference; meetings of Maternal Death Control Management System Team; Management Reviews; Independent Audits; Blood-letting activities.   Examples of informal activities are outing of the Maternal Death Control Management System Team and individual staff working on Maternal Death Control Management System.

8. The documentation materials shall be in any of the following forms: pictures (still and videos); reports; minutes; and others.

9. The documentation materials and records shall be used for evidentiary and historical purposes.

10. All documentation materials and records shall be digitalized.

11. All documentation materials and records shall be subjected to the archiving policies and procedures of the Maternal Death Control Management System and that of the hospital / medical center.

12. The documentation materials shall be classified into two: documents and records.  Based on ISO 9001, a document is a documentation material that contains the description of policies and procedures, specification, drawing, work instruction and the like.  A record is a documentation material that provides evidence of compliance with established requirements and effectiveness of the operation of quality management system.

13, Documents shall include primarily the Manual of Operations of the Maternal Death Control Management System.

14, Records shall include patient medical records; maternal death statistics; minutes of meetings; independent audits; customary satisfaction surveys and the like.

15. There shall be a system of control of documents and records, in terms of legibility; currency; easy retrieval; safekeeping; security; and confidentiality.

Archiving

16. There shall be a documented system of archiving of documents and records of the Maternal Death Control Management System.

17. The archiving system must take in consideration control of documents and records; safekeeping; security; confidentiality; and ease of retrieval.

18. There shall be digitalization of hard copies of documents and records of the Maternal Death Control Management System.

19. The Medical Records Department shall safekeep all medical records of pregnant patients.

20. The Maternal Death Control Management System Chair or the Department of Obstetrics-Gynecology shall safekeep all documents and records of the Maternal Death Control Management System.

21. There shall be policies on retention period of the print and digital copies of the documents and records of the Maternal Death Control Management System.  The retention period for hard copies of documents and records except medical records is 3 years.  The retention period for medical records is 25 years.  The retention period for digital copies of documents and records is 5 years.

22. The following are the criteria and indicators for performance excellence of Documentation and Archiving:

Criteria and Indicators for Performance Excellence of Documentation and Archiving

Criteria and Indicators for Performance Excellence of Documentation and Archiving

Audit Results

Areas for Improvement

There is adequate documentation of formal activities of the Maternal Death Control Management System.

-          Minutes of monthly meetings of the Maternal Control Management System Team

-          Minutes of Management Reviews

-          Reports of Independent Audits

   

There is control of documents (legibility; currency; easy retrieval; safekeeping; security; and confidentiality).

   

There is control of records (legibility; currency; easy retrieval; safekeeping; security; and confidentiality)

   

There is digitalization of documents and records

   

The retention period for patient medical records is being followed.

   

The retention period for hard copies of documents and records is being followed.

   

The retention period for digital copies of documents and records is being followed.