NABH Audit Checklist 2026: 200+ Documents Your Hospital Needs

Preparing for a NABH audit is overwhelming. With 10 chapters, 100+ standards, and 600+ objective elements — knowing exactly which documents you need is half the battle. This chapter-wise audit checklist covers every document, SOP, and policy your hospital needs.

How to Use This Checklist

NABH full accreditation covers 10 chapters. Each chapter has specific standards, and each standard has objective elements. For every objective element, you need documentary evidence. This checklist lists the most critical documents for each chapter.

NABH requires 200+ documents across 10 chapters.

Digital HMS reduces document preparation time by 60%.

Chapter 1: Access, Assessment & Continuity of Care (AAC)

This chapter covers the patient journey from entry to discharge and follow-up.

• Patient registration policy and process
• Admission and discharge criteria for each unit
• Triage protocol for emergency patients
• Referral and transfer policy (inter and intra-hospital)
• Patient identification policy (two-identifier)
• Waiting time standards and monitoring records
• Discharge planning process documentation
• Follow-up appointment system records
• LAMA (Leave Against Medical Advice) policy
• Ambulance transfer protocols

Chapter 2: Care of Patients (COP)

Standards for clinical care delivery across all departments.

• Clinical protocols for top 10 conditions
• Informed consent templates (procedure-specific)
• Nursing care plans and records
• ICU admission/discharge criteria (APACHE/SOFA scoring)
• Operation theatre safety checklist (WHO 3-phase)
• Anesthesia pre-assessment form
• Pain assessment and management protocol
• Nutritional assessment and diet management
• Restraint use policy
• End-of-life care policy
• Obstetric and neonatal care protocols
• Organ transplant protocols (if applicable)

Chapter 3: Management of Medication (MOM)

Pharmacy and medication safety standards.

• Hospital drug formulary
• High-alert medication list and protocols
• Look-Alike Sound-Alike (LASA) drug management
• Drug storage, dispensing, and administration SOPs
• Narcotic and controlled drug register
• Adverse drug reaction (ADR) reporting forms
• Cold chain maintenance records
• Medication error reporting system
• Anti-microbial stewardship program documentation
• Sample drug management policy

Chapter 4: Patient Rights & Education (PRE)

• Patient rights charter (displayed in hospital)
• Patient/family education records
• Informed consent policy and forms
• Patient grievance redressal mechanism
• Privacy and confidentiality policy
• Patient feedback forms and analysis reports
• Financial counseling process documentation
• Research ethics committee records (if applicable)
• Organ donation counseling protocol

Chapter 5: Hospital Infection Control (HIC)

• Infection control manual
• Hand hygiene policy and audit records
• Surveillance data (SSI, CLABSI, CAUTI, VAP rates)
• Antibiogram (annual)
• Biomedical waste management records
• Sterilization and disinfection SOPs
• Needle-stick injury protocol and records
• Isolation precaution policies
• Kitchen and laundry hygiene SOPs
• Environmental sampling records
• CSSD (Central Sterile Supply) protocols

Chapter 6: Continuous Quality Improvement (CQI)

• Quality improvement program charter
• Quality indicator list with benchmarks
• Monthly/quarterly quality indicator data
• Root Cause Analysis (RCA) for sentinel events
• PDCA cycle documentation for quality projects
• Clinical audit reports
• Near-miss and incident reporting records
• Patient safety committee meeting minutes
• Morbidity and mortality meeting records
• Benchmarking data with national standards

Chapter 7: Responsibilities of Management (ROM)

• Hospital organogram
• Strategic plan and annual operating plan
• Governing body meeting minutes
• Budget allocation and utilization records
• Ethics committee records
• Outsourced services agreements and monitoring
• Medical staff credentialing files
• Privileging documents for clinical staff
• Leadership development programs

Chapter 8: Facility Management & Safety (FMS)

• Fire safety certificate and inspection records
• Fire drill records (quarterly)
• Electrical safety inspection records
• Medical gas pipeline testing records
• DG set maintenance records
• Water quality testing reports
• Pest control records
• Hazardous material management SOPs
• Disaster management plan
• Safety committee meeting minutes
• Equipment maintenance schedules

Chapter 9: Human Resource Management (HRM)

• Staff recruitment and onboarding policy
• Credential verification records
• Staff training plan and records
• Performance appraisal system
• Staff health screening records
• Staff satisfaction surveys
• Staff wellness programs documentation
• Nurse-to-patient ratio documentation
• Continuing medical education (CME) records

Chapter 10: Information Management System (IMS)

• Medical records policy
• Record retention and destruction policy
• Data security and access control policies
• IT disaster recovery plan
• ICD-10 coding compliance records
• MIS reports and dashboard outputs
• Hospital information system user access logs
• Data backup and restoration test records
• ABDM integration records

Checklist Summary by Chapter

Frequently Asked Questions

How many chapters are in NABH?

NABH full accreditation has 10 chapters covering all aspects of hospital quality: patient access, clinical care, medication, patient rights, infection control, quality improvement, management, facility safety, HR, and information systems.

How long does NABH audit preparation take?

Full NABH accreditation preparation typically takes 12-18 months. With HMS software that has built-in NABH compliance (like Adrine), this can be reduced to 6-9 months as many documents are auto-generated.

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