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Documentation NABH 5 TH Edition

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509 views4 pages

Documentation NABH 5 TH Edition

Uploaded by

singh_rukmini6636
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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The National Accreditation Board for Hospitals & Healthcare Providers (NABH) in India establishes

various standards for accreditation of healthcare organizations. One of the crucial aspects of the
NABH accreditation process is the submission of documentary evidence to demonstrate compliance
with these standards. The evidence varies across different categories and standards. Below is a
general list of documentary evidence, categorized by NABH standard:

1. Patient Care and Rights (Standard 1: Rights of Patients)

Documentary Evidence:

 Patient information and consent forms


 Rights and responsibilities pamphlet or document
 Complaints and feedback register
 Information on patient rights in patient admission forms
 Patient satisfaction surveys
 Documentation of patient’s informed consent for treatment
 Record of grievances and resolutions

2. CARE OF PATIENTS (STANDARD 2: CARE OF PATIENTS)

Documentary Evidence:

 Patient care protocols and procedures


 Clinical guidelines and care pathways
 Nursing care plans
 Records of patient monitoring
 Evidence of multidisciplinary care coordination
 Patient medical records
 Discharge summaries

3. MANAGEMENT OF MEDICATION (STANDARD 3: MEDICATION MANAGEMENT)

Documentary Evidence:

 Medication management policy and procedure


 Medication administration records
 Drug inventory management and inspection reports
 Documentation of adverse drug events and actions
 Pharmacy logs and prescription records
 Staff training records for handling medications
 Audits of medication usage

4. HOSPITAL INFECTION CONTROL (STANDARD 4: HOSPITAL INFECTION CONTROL)

Documentary Evidence:

 Infection prevention and control policy


 Infection control audits and reports
 Environmental cleaning records
 Reports on sterilization and disinfection processes
 Staff training records on infection control
 Incident reporting related to infections
 Surveillance reports on hospital-acquired infections (HAIs)

5. PATIENT SAFETY (STANDARD 5: PATIENT SAFETY)

Documentary Evidence:

 Safety policies and protocols


 Incident and accident reports
 Patient safety audits
 Evidence of risk management practices
 Records of staff training on safety protocols
 Safety drills (fire, earthquake, etc.) records
 Equipment calibration and maintenance records

6. CONTINUAL QUALITY IMPROVEMENT (STANDARD 6: QUALITY MANAGEMENT)

Documentary Evidence:

 Quality improvement (QI) plan and policy


 QI team meeting minutes
 Performance indicators and benchmarks
 Data collection and analysis reports for QI initiatives
 Corrective and preventive action (CAPA) reports
 Audit results
 Patient care outcome data

7. FACILITY MANAGEMENT AND SAFETY (STANDARD 7: FACILITY MANAGEMENT AND SAFETY)

Documentary Evidence:

 Safety policies and procedures


 Hazard identification and risk assessment reports
 Building maintenance logs
 Emergency preparedness and disaster management plans
 Inspection records for electrical, mechanical, and other safety systems
 Fire safety records, including fire drill logs
 Documentation of pest control measures
 Patient safety signage

8. INFORMATION MANAGEMENT SYSTEM (STANDARD 8: INFORMATION MANAGEMENT)

Documentary Evidence:

 Electronic medical records (EMR) policies


 Data privacy and security policies (HIPAA compliance, etc.)
 Evidence of staff training on handling patient data
 Audit trails for accessing medical records
 Backup and disaster recovery plans
 Data integrity and accuracy checks
 Access control lists

9. HUMAN RESOURCE MANAGEMENT (STANDARD 9: HUMAN RESOURCE MANAGEMENT)

Documentary Evidence:
 Staff recruitment and selection procedures
 Staff qualification and training records
 Job descriptions for all staff positions
 Records of performance evaluations
 Staff attendance and leave records
 Credentialing and privileging documentation
 Compliance with legal and ethical standards

10. PATIENT EDUCATION (STANDARD 10: PATIENT EDUCATION)

Documentary Evidence:

 Patient education materials (brochures, videos, etc.)


 Documentation of education provided to patients and families
 Records of health education sessions
 Patient education feedback surveys
 Educational programs for staff to enhance patient education

11. ORGANIZATION LEADERSHIP (STANDARD 11: LEADERSHIP)

Documentary Evidence:

 Organizational chart
 Leadership team meeting minutes
 Policies on decision-making processes
 Evidence of continuous leadership training
 Risk management policies
 Vision, mission, and values statements
 Documentation of strategic planning and goal-setting

12. PATIENT PRIVACY AND CONFIDENTIALITY (STANDARD 12: PRIVACY AND CONFIDENTIALITY)

Documentary Evidence:

 Policies related to privacy and confidentiality (e.g., data protection)


 Consent forms for information sharing
 Training records for staff on patient confidentiality
 Documentation of data breaches and resolutions
 Secure storage and access control protocols for patient records

13. QUALITY INDICATORS AND AUDIT (STANDARD 13: PERFORMANCE MONITORING)

Documentary Evidence:

 Data collection protocols


 Internal and external audit reports
 Performance review records
 Corrective action and follow-up records
 Patient outcome measures
 Benchmarking data and reports

14. COMPLIANCE AND LEGAL (STANDARD 14: COMPLIANCE WITH LEGAL REQUIREMENTS)

Documentary Evidence:
 Licenses and accreditations
 Compliance with national and local regulations
 Evidence of adherence to healthcare-related laws
 Staff training on legal and regulatory requirements
 Documentation of legal actions and resolutions (if applicable)

15. PATIENT FEEDBACK AND SATISFACTION (STANDARD 15: PATIENT FEEDBACK)

Documentary Evidence:

 Patient satisfaction surveys and feedback forms


 Grievance handling policy and records
 Documentation of follow-up actions on patient complaints
 Results of patient satisfaction reviews and surveys
 Patient feedback trends and improvement initiatives

ADDITIONAL DOCUMENTATION:

 General Administrative Documents:


 Organizational policies and procedures
 Accreditation application forms and supporting documents
 Staff rosters and certifications
 Annual reports and self-assessment documents
 Inventory management and procurement records

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