Checklist of documents for NABH accreditation preparation 2025

Checklist of documents for NABH accreditation preparation 2025

Chapter 1:(AAC) Documents related to Access, Assessment and Continuity of Care

1. Registration and admission of patients (OPD, IPD, Emergency)

2. Managing patients during non-availability of beds

3. Transfer-in of the patient to the hospital

4. Transfer or referral of unstable patients to another facility

5. Transfer or referral of stable patients to another facility

6. Initial evaluation of patients (outpatients, inpatients, and emergency patients)

7.  Laboratory scope of tests

8. Ordering lab tests, collection, identification, handling, transportation, processing, and disposal of specimens.

9. Timeframe for obtaining lab test results

10. Critical lab results and quick intimation

11. Outsourcing of lab tests

12.   Laboratory quality assurance programme

13.   Laboratory safety programme

14.   Imaging scope of tests

15.   Identification and secure transportation of patients to and from the imaging department.

16.   Timeline for the availability of imaging findings

17.   Critical imaging results and prompt intimation

18.   Outsourcing of imaging tests

19.   Imaging quality assurance programme

20.   Radiation safety programme

21.   Discharge procedure (includes MLC discharge and absconding instances).

22.   Discharge against medical advice

23.   Death discharge

Chapter 2:(COP)Documents related to Care of Patients

24.   Uniform care policy

25.   Handling of medico-legal cases 

26.   Triage of patients in emergency

27.   Managing dead on arrival cases

28.   Identifying potential community emergencies, epidemics, and disasters.

29.   Plan for handling all probable disaster situation

30.   Handling of mass casualty situation

31. Clinical guidelines for addressing diverse emergency cases (adults and children).

 32. Quality assurance programme for emergency services

 33. Equipment and emergency medicine checklist for ambulances

 34. Cardiopulmonary resuscitation and code blue procedure

 35. Reasonable use of blood and blood products.

 36. Transfusion of blood or blood products

 37. Availability and transfusion of blood/blood components in an emergency.

 38. Patient care in the ICU and HDU.

 39. Admission and discharge criteria for the ICU and HDU40.   Managing situation of bed shortage in ICU

41.   Quality assurance programme of ICU

42.   Care of vulnerable patients

43.   Provision of obstetric care services

44.   Care of Paediatric patients

45.   Administration of moderate Anaesthesia

46.   Monitoring of patients under anaesthesia

47.   Criteria for discharge from recovery area

48.   Care of surgical patients

49.   Surgical safety policies and practices

50.   Quality assurance program of surgical services

51.   Organ transplant policy and process

52.   Standard treatment protocols

53.   Restraint of patient

54.   Pain management

55.   Provision of rehabilitative services

56. Conducting clinical research activities.

 57. Nutritional assessment, re-evaluation, and nutritional therapy

58.   End of life care

Chapter 3:(MOM) Documents related to Management of Medication

59.   Hospital formulary

60. Process of acquiring drugs in the formulary.

 61. Process of acquiring medicine that is not mentioned in the formulary

 62. Storage of medications

 63. Safe storage and handling of medications that appear and sound alike

 64. List of emergency medications and their storage

 65. Prescription for medicine

 66. Policy and procedure for spoken orders of medication67.   List of high risk medicines

68.   Safe dispensing of medicines

69.   Medication recall

70.   Procedure for near expiry medicine

71.   Labelling requirements of medicine

72.   Safe administration of medication

73. Policy regarding patients' self-administration of medication

74. Monitoring patients following medication administration

75. Documenting and reporting drug errors, adverse events, and near misses.

76. Narcotic and psychotropic medication administration procedures77.   Usage of chemotherapeutic medications

78.   Disposal of waste medication (cytotoxic)

79. Use of radioactive pharmaceuticals (safe storage, preparation, handling, distribution, and disposal).

80. Use of implantable prosthesis (procurement, storage, issuing, and recordkeeping)

81.   Acquisition of medical supplies and consumables

Chapter 4:(PRE) Documents related to Patients’ Rights and Education

82.   Patients’ rights and responsibilities

83.   Informed consent taking process 

84. List of operations that require informed consent.

85. A uniform pricing policy

86. Effective communication with patients and families.

87. System for obtaining and managing patient complaints.

Chapter 5:(HIC) Documents related to Hospital Infection Control

88.   Infection control programme

89.   Infection surveillance

90.   Identification of high risk areas

91. Standard Precaution/Universal Precaution for Infection Control

92.   Safe injection and infusion practices

93.   Cleaning, disinfection and sterilization practices

94.   Antibiotic policy

95.   Laundry and linen management processes

96.   Kitchen sanitation and food handling

97.   Housekeeping procedures

98.   Infection control care bundles

99.   Handling outbreak of infections

100.   Sterilization process

101.  Biomedical waste handling process

Chapter 6: (PSQ) Documents related to PATIENT SAFETY & Quality Improvement

102.       Organization wide quality improvement programme

103.       Quality indicators, including their methods, aims, and monitoring

104.       Patient safety programme

105.       Clinical audit system

106.       Incident reporting, analysis and corrective preventive action system

107.       Definition and lists of sentinel events

108.       Examination of sentinel incidents

Chapter 7:(ROM)Documents related to Responsibilities of Management 

109. Vision, mission, and values of the organization.

110. Strategic and operational plan for the organization

111. Organogram.

112. Managing compliance with rules, regulations, licenses and permissions.

113. Scope of services for each department

114. Administrative policies and procedures (attendance, absence, conduct, replacement, etc.)

115. Employee rights and obligations.

116. Service Standards of Organizations

Chapter 8: (FMS) Documents related to Facility Management and Safety

117. Dispose of non-functional objects and scrap materials.

118. Facility inspection round

119. Current drawings and layout

120. Facility maintenance plan

121. Preventive and breakdown maintenance plan.

122. Water management maintenance plan.

123. Electrical system maintenance plan

124. HVAC system maintenance plan

125. IT network maintenance plan

126. Equipment replacement and disposal

127. Managing medical gases: purchase, handling, storage, distribution, usage, and replenishment.

128. Managing fire (Code Red alert) and non-fire crises

129. List of hazardous materials in the organization

130. Hazardous material handling (sorting, labeling, storage, transportation, and disposal)

131. Handling spills of hazardous materials, including blood.

Chapter 9: (HRM) Documents related to Human Resources Management

132. Human Resources Plan of the Organization

133. Job descriptions for each staff category

134. Recruitment and selection process

135. New staff induction program

136. Training and development policy

137. Employee appraisal system

138. Disciplinary and grievance handling system

139. Addressing employee health needs

140. Medical professionals' credentials and privileges

141. Nursing professionals' credentials and privileges.

Chapter 10: (IMS) Documents related to Information Management System

142. Managing the information demands of the company.

143. Document Control Process

144. Data management (dissemination, storage, retrieval)

145. Authorization policy for medical record entries

146. Medical record management.

147. Ensuring the confidentiality, security, and integrity of documents, data, and information

148. Maintaining the patient's clinical record, data, and information.

149. Destruction of Medical Records

150. Medical record review.