By Aarogentix · · 8 min read
This is a planning list, not the standard. Requirements differ by hospital category and change between editions. Always check the current standards published by NABH and confirm details with your assessor.
Assessors look for evidence that you do the safe thing every day, and that you notice and fix problems. Records are that evidence. The earlier a register starts, the more history you can show. Use this list as a starting point for your own checklist.
Clinical records for every patient
- A unique patient ID and the identifiers you use to confirm who the patient is
- Initial assessment, with allergies and history
- Doctor’s and nurse’s notes, with date, time and signature
- Medication orders and the record of what was given
- Consent for procedures, anaesthesia, blood and high-risk care
- Discharge summary given to the patient, with follow-up advice
Registers specific to hospital work
- Medico-legal cases (MLC) register
- Death records and mortality reviews
- Leave against medical advice (DAMA) records
- Narcotic and controlled medicine register, matched to stock
- Blood transfusion records and reactions, if you issue blood
- Biomedical waste records
Safety and quality records
- Incident and near-miss reports, with review and corrective action
- Sentinel events, with analysis
- Medication errors and adverse drug reactions
- Infection control surveillance and hand hygiene audits
- Patient restraint records, where restraint is used
- Patient feedback and complaints, with response and closure
- Quality indicators tracked month by month
Facility and equipment
- Equipment list with maintenance and calibration dates
- Fire safety checks and mock drills, with who attended
- Emergency trolley and oxygen checks
- Cold-chain temperature logs for medicines and vaccines
Staff records
- Qualification and registration documents for clinical staff
- Induction and regular training, with attendance
- Duty rosters and leave
- Staff health and vaccination records where your policy requires them
Patient rights and information
- A displayed statement of patient rights and responsibilities
- Price list for services, available to patients
- Information given about the plan of care and expected cost
- Policy and records for access to a patient’s own medical record
How to keep these without drowning in files
- Give every register one owner and a monthly review date.
- Record at the moment of the event, not at the end of the week.
- Review a sample every month and write what you changed.
- Keep records for the period your policy and the law require, and be able to find them quickly.
A hospital system helps most with the registers and indicators you would otherwise rebuild by hand every month. See what registers that help you prepare for NABH look like in Aarogentix, and read the preparation checklist for the steps around them.
Talk to us and try the registers with your own data on a trial.