Documentation is the backbone of NABH accreditation. Without proper policies, SOPs, registers, and forms, even the best hospital will fail assessment. This comprehensive checklist covers all 10 NABH chapters with specific documents you need to prepare.
How to Use This Checklist
- Go through each chapter systematically
- Mark documents as Draft → Under Review → Approved
- Assign owners for each document
- Set review dates (annual review required)
- Use HMS software to auto-generate many documents
Complete Documentation by Chapter
1AAC - Access, Assessment & Continuity of Care
Patient Registration Policy
Admission & Discharge Policy
Transfer Policy (Internal & External)
Referral Policy
Initial Assessment Forms
Reassessment Guidelines
Discharge Summary Format
Leave Against Medical Advice (LAMA) Form
2COP - Care of Patients
Clinical Care Protocols (Specialty-wise)
Nursing Care Plans
Pain Assessment Policy
End of Life Care Policy
High-Risk Patient Identification
Restraint Use Policy
Blood Transfusion Policy
Surgical Safety Checklist
3MOM - Management of Medication
Medication Management Policy
High-Alert Medication List
Look-Alike Sound-Alike (LASA) List
Drug Formulary
Prescription Writing Guidelines
Medication Error Reporting Form
Adverse Drug Reaction Form
Emergency Drug List & Checking Register
4PRE - Patient Rights & Education
Patient Rights Policy
Informed Consent Forms
Consent for Procedures/Surgery
Consent for Anesthesia
Patient Grievance Policy
Feedback Forms
Patient Education Materials
Information About Hospital Services
5HIC - Hospital Infection Control
Infection Control Manual
Hand Hygiene Policy
Biomedical Waste Management Policy
Needle Stick Injury Protocol
Antibiotic Stewardship Policy
Surveillance Forms (SSI, CLABSI, CAUTI, VAP)
Outbreak Management Protocol
Disinfection & Sterilization Policy
6CQI - Continuous Quality Improvement
Quality Policy
Quality Indicator List with Targets
Monthly Quality Data Analysis
CAPA (Corrective & Preventive Action) Register
Incident Reporting Policy
Sentinel Event Policy
Root Cause Analysis Format
Quality Committee Meeting Minutes
7ROM - Responsibilities of Management
Hospital Organogram
Governing Body Meeting Minutes
Vision, Mission, Values Statement
Strategic Plan
Bylaws & Rules
Medical Staff Credentials File
Privilege Matrix
Ethics Committee Records
8FMS - Facility Management & Safety
Fire Safety Policy
Fire Drill Records
Facility Inspection Checklist
Equipment Maintenance Records
Calibration Records
Disaster Management Plan
Mock Drill Records
Safety Audit Reports
9HRM - Human Resource Management
Recruitment Policy
Job Descriptions for All Roles
Orientation Program Records
Training Needs Assessment
Training Calendar & Records
Performance Appraisal Records
Staff Health Records
Attendance & Leave Records
10IMS - Information Management System
Medical Records Policy
Records Retention Policy
Health Information Security Policy
Data Backup Policy
Patient Data Confidentiality Policy
Medical Records Audit
Abbreviation Policy
Legibility Standards
Additional Required Registers
- OPD Register
- IPD Register
- OT Register
- Blood Transfusion Register
- Narcotic Drug Register
- Equipment Log Book
- Visitor Register
- Complaint Register
- Incident Register
- Staff Training Register
Tips for Documentation Success
- Start Early: Documentation takes 6-12 months to prepare properly
- Assign Ownership: Each policy needs an owner responsible for updates
- Version Control: Track document versions and approval dates
- Staff Training: Staff must know the policies, not just have them
- Regular Audits: Conduct internal audits to ensure compliance
How Software Helps
Modern hospital management software can significantly reduce documentation burden:
- Auto-Generated Records: Discharge summaries, prescriptions created automatically
- Built-in Templates: Pre-approved forms and consent templates
- Quality Dashboards: Real-time tracking of NABH indicators
- Audit Trails: Complete logs for assessor review
- Digital Signatures: Proper authentication of documents
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