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    NABH Checklist

    Uploaded by

    MargretSneha
    This document provides an assessment of Nalam Hospital's eligibility for NABH accreditation based on 36 requirements. It finds that the hospital meets some requirements like generating UHIDs, having certain licenses and registrations. However, it is not fully compliant with many important requirements like having all necessary signage and training programs, maintaining complete patient records and diagnostic documentation. Several licenses and safety protocols also need to be obtained or improved to be fully eligible for NABH accreditation.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    NABH Checklist

    Uploaded by

    MargretSneha
    742 views3 pages
    This document provides an assessment of Nalam Hospital's eligibility for NABH accreditation based on 36 requirements. It finds that the hospital meets some requirements like generating UHIDs, having certain licenses and registrations. However, it is not fully compliant with many important requirements like having all necessary signage and training programs, maintaining complete patient records and diagnostic documentation. Several licenses and safety protocols also need to be obtained or improved to be fully eligible for NABH accreditation.

    Original Description:

    The Sample document on NABH eligibility for small hospital.

    Original Title

    NABH checklist

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    © © All Rights Reserved

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    This document provides an assessment of Nalam Hospital's eligibility for NABH accreditation based on 36 requirements. It finds that the hospital meets some requirements like generating UHIDs, having certain licenses and registrations. However, it is not fully compliant with many important requirements like having all necessary signage and training programs, maintaining complete patient records and diagnostic documentation. Several licenses and safety protocols also need to be obtained or improved to be fully eligible for NABH accreditation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    742 views3 pages

    NABH Checklist

    Uploaded by

    MargretSneha
    This document provides an assessment of Nalam Hospital's eligibility for NABH accreditation based on 36 requirements. It finds that the hospital meets some requirements like generating UHIDs, having certain licenses and registrations. However, it is not fully compliant with many important requirements like having all necessary signage and training programs, maintaining complete patient records and diagnostic documentation. Several licenses and safety protocols also need to be obtained or improved to be fully eligible for NABH accreditation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    NALAM HOSPITAL - NABH ELIGIBILITY

    Date: 27/06/2022
    S.NO REQUIREMENTS REMARKS
    1.         30% Occupancy Rate 20beds 

    2.         Generate UHID Yes

    3.         Hospital Registration License - Ownership License Yet to be verified

    4.         Clinical Establishment Act Registration Yes - 10beds

    5.         Pharmacy Yes

    6.         Scan - PCPNDT Yes

    7.         Fire  -NOC/License No (renewal is missed)

    8.         Pollution Control Board- BMWM Yes - 10 beds

    9.         Air Clearance – PCB Yes - 20 beds

    10.     Water Clearance – PCB Yes - 20 beds


    11.     AERB – X-ray NA
    12.     Narcotics - NDRC No - optional
    13.     DL2 License - Spirit License No - optional
    14 MTP License
    15 Lift License No - optional
    16 MOU for Outsourced services
    ·         Ambulance Need to arrange
    ·         Lab 
    ·          Scan
    ·         X-ray  
    ·         CT
    ·         MRI
    ·         Blood bank
    ·         Referral Hospital
    17 SIGNAGE: Intiated, few under 
    ·         Fire safety - radium exit sign process.
    ·         Fire Safety -directional sign (arrows)
    ·         Fire Safety - extinguisher - PASS
    ·         Fire Safety - escape route plan
    ·         Fire Safety - ramp signage
    ·         Fire Safety - hydrant signage
    ·         Biomedical waste segregation
    ·         Bio Hazard
    ·         Pt Rightsand responsibility
    ·          Floor plan – escape route
    ·         Pt . information signage
    ·         Educational posters.
    ·         CODES  - contact number 
    ·         CODES  - process
    ·         Hospital ownership
    ·         Scope of services
    ·         Traiff
    ·         Pediatric scope of service
    ·         OBG scope of service
    ·         How to voice a complaint
    ·         Entry restriction
    ·         Directional signage
    ·         Floor Directory
    ·         No smoking
    ·         Visiting time
    ·         Electrical safety
    ·         Internal signages
    18 Department Training Under process
    ·            Nursing
    ·         Laboratory Safety
    ·         X-ray safety
    ·         HIC
    ·         House Keeping
    ·         Safety Training
    ·         CODES
    ·         HR
    ·         Hospital policies and protocols.
    19 Case sheet
    ·         Admission consent available
    ·         Surgery consent available
    ·         Anaesthesia  consent available
    ·         High risk consent available
    ·         Blood transfusion consent
    ·         Admission form available
    ·         Care plan - doctors initial assessment available
    ·         Doctors progress notes available
    ·         Drug chart - orders available
    ·         Drug chart - Administration available
    ·         NSG initial assessment
    ·         Monitoring chart available
    ·         Pre op checklist no
    ·         Operation notes no
    ·         Post operative orders no
    ·         PAC and Immediate anaestheia checklist no
    ·         Intra op monitoring no
    ·         Post Op and recovery criteria no
    ·         Blood transfusion form - monitoring no
    ·         Monitoring chart no
    ·         ICU monitoring chart NA
    ·         ICU consent NA
    Diagnostics
    ·         Nominal Register available
    ·         Critical Values docuementation lab- available
    ·         QC no
    ·         Indicators no
    ·         TAT no
    ·         Displays - warning sign no
    ·         PCPNDT signage yes
    20 ·         AERB signage Yes
    21 ·         TLD badge Yes - 1
    22 ·         Lead apron screening No
    23 ·         Thyroid collar Yes
    24 MLC register No
    25 Transfer out register No
    26 AR copy and Police intimation records Yes
    27 Wound certificates Yes
    28 Death register Yes
    29 Birth register Yes
    30 IUCD registers Yes
    31 Scan Register Yes
    32 MTP Register Yes
    33 OT register Yes
    34 IP Register Yes
    35 Nominal – Diagnostic services Yes
    36 Narcotics stock and usage register No

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