Key takeaways
- Documents alone don't pass NABH — records showing the documents are followed matter as much.
- Organise documentation by the 10 chapters: AAC, COP, MOM, PRE, IPC, PSQ, ROM, FMS, HRM, IMS.
- Every document needs control: number, version, approval, issue date, review date and distribution list.
- Statutory licences and committee minutes are among the first things assessors check.
First, set up document control
Before writing a single policy, decide how documents are controlled. Each document should show a document number, version, prepared/reviewed/approved by, issue date and next review date, and you need a master list showing where each copy lives. Obsolete versions must be withdrawn. This system is itself assessed.
Chapter-wise checklist
AAC — Access, Assessment and Continuity of Care
- Registration, admission, transfer, referral and discharge procedures
- Scope of services displayed; admission criteria for ICU and special units
- Initial assessment by doctors and nurses with defined timeframes; reassessment
- Laboratory and imaging processes, critical results reporting, and their safety programmes
- Discharge summary format; discharge against medical advice; death summary
The full chapter, element by element: NABH AAC chapter guide.
COP — Care of Patients
- Uniform care across the hospital; clinical protocols for common conditions
- Emergency care, triage and code blue / rapid response procedures
- High-risk patients and procedures; restraints; vulnerable patients
- Blood and blood component transfusion
- Sedation and anaesthesia; surgical safety checklist; OT procedures
- Pain management, nutrition, rehabilitation and end-of-life care
- Obstetric and paediatric care where offered
The full chapter, element by element: NABH COP chapter guide.
MOM — Management of Medication
- Hospital formulary and procurement procedure
- Storage, cold chain, expiry management and segregation of high-alert and look-alike sound-alike medicines
- Narcotics and controlled drugs control
- Prescription, dispensing and administration procedures; medication reconciliation
- Adverse drug reaction monitoring and medication error reporting
The full chapter, element by element: NABH MOM chapter guide.
PRE — Patient Rights and Education
- Patient and family rights and responsibilities, displayed in local languages
- General and procedure-specific informed consent
- Privacy, confidentiality and protection from abuse
- Complaint and grievance procedure with records
- Patient education material and records
The full chapter, element by element: NABH PRE chapter guide.
IPC — Infection Prevention and Control
- Infection control manual; IPC team and committee
- Surveillance of healthcare-associated infections (device-associated infections, surgical site infections) with data
- Hand hygiene programme with audits
- Cleaning, disinfection and sterilisation (CSSD) procedures and records
- Antimicrobial stewardship / antibiotic policy
- Biomedical waste management; needle-stick injury and post-exposure procedures; staff immunisation
The full chapter, element by element: NABH IPC chapter guide.
PSQ — Patient Safety and Quality Improvement
- Quality and patient safety programme document
- Quality indicators — definitions, data collection, monthly analysis
- Incident and sentinel event reporting, root cause analysis and corrective action
- Clinical audit cycles with re-audit; risk register
- Patient-reported outcome and experience measures where applicable
The full chapter, element by element: NABH PSQ chapter guide.
ROM — Responsibility of Management
- Organisation chart, governance structure and responsibilities
- Vision, mission and strategic or annual plan
- Code of ethics; management of conflicts of interest
- Contract management for outsourced services
The full chapter, element by element: NABH ROM chapter guide.
FMS — Facility Management and Safety
- Facility safety and security plan; fire safety plan with mock drill records
- Disaster management plan with drills
- Equipment inventory, preventive maintenance and calibration records
- Medical gas, water quality and electrical safety management
- Hazardous materials management
The full chapter, element by element: NABH FMS chapter guide.
HRM — Human Resource Management
- Recruitment procedure, job descriptions, staffing plan
- Credentialing and privileging of doctors and nurses, with verified registrations
- Induction and ongoing training records; competency assessment
- Performance appraisal; staff health check-ups; grievance and disciplinary procedures
The full chapter, element by element: NABH HRM chapter guide.
IMS — Information Management System
- Medical records policy — content, completeness audits, retention and destruction
- Confidentiality, access control and release of information
- Use of standard terminology, abbreviations list and coding
- Hospital information system procedures and data backup
The full chapter, element by element: NABH IMS chapter guide.
Committees assessors expect to see minutes from
Quality and patient safety · Infection control · Pharmacy and therapeutics · Medical records · Safety / facility · Ethics (where applicable) · Blood transfusion (where applicable) · Grievance redressal
Quality indicators to start with
- Time for initial assessment in emergency and in-patients
- Medication errors and adverse drug reactions reported
- Hand-hygiene compliance; device-associated infection rates; surgical site infection rate
- Patient falls and pressure injuries
- Return to OT, unplanned ICU readmission, mortality rates
- Patient satisfaction; waiting time in OPD
- Percentage of incomplete medical records
The 6th Edition's KPI annexure defines 32 hospital-wide and 18 department-specific indicators, each with a formula, unit and sampling rule. See the full NABH quality indicators list.
Statutory licences
Clinical establishment registration · Fire NOC · Biomedical waste authorisation · Pollution control consents · AERB registration/licence · PC-PNDT registration · Drug licence · Narcotics licence where applicable · FSSAI for kitchen · Lift licence · Blood centre licence where applicable · Ambulance registration · Electrical safety and DG set approvals as applicable. See licences and registrations.
The test that matters
For every document, ask: can a staff member on a night shift explain it, and is there a record showing it was followed last week? If the answer is no, the document is a liability, not evidence. We write documentation around how your teams actually work — see our method.
Frequently asked questions
What documents are required for NABH accreditation?
Hospitals typically need policies and SOPs for each of the ten chapters (from admission and assessment to medication, infection control, safety, HR and records), registers and forms that record daily practice, committee terms of reference and minutes, quality indicator reports, training records and all statutory licences. The exact set depends on your services.
How many SOPs are needed for NABH?
There is no fixed number. NABH assesses whether each applicable objective element is met, so the number of policies and SOPs depends on your services. A small hospital may have fewer, broader documents; a large one more detailed procedures. Fewer documents that staff actually follow beat a thick manual nobody reads.
Can we buy ready-made NABH documents?
Templates can save time, and NABH's free E-Mitra tool provides sample policies for entry-level applicants. But copied documents that do not describe what your staff actually do are a common reason for non-conformities, because assessors interview staff and check records against the policy.
What is document control in NABH?
It is the system that ensures every policy and form is approved, numbered, version-controlled, issued to the right places, reviewed on schedule and withdrawn when obsolete. Assessors check that staff use the current version.
Official sources
Fees and rules change. Always confirm on the official page before you apply.
Get a free gap assessment for your facility
Tell us your facility type, bed or chair count and city. Dr. Ashutosh Sharma will tell you which NABH programme fits, what it will cost and how long it will realistically take — before you commit to anything.
Read next
- NABH Quality Indicators: The Complete 6th Edition KPI List (32 + 18)All 32 hospital-wide and 18 department-specific NABH 6th Edition quality indicators, with units, PSQ links, sampling rules and how to measure them.
- NABH 6th Edition Standards: Chapters, Objective Elements and How Hospitals Are ScoredNABH 6th Edition explained: 10 chapters, 100 standards, 639 objective elements, Core to Excellence levels, scoring rules and key dates.
- NABH Accreditation Process: 10 Steps from Gap Analysis to Certificate (2026)The NABH accreditation process in 10 steps: programme choice, gap analysis, documents, 3-month implementation, assessments and surveillance.
- How our NABH consultancy worksOur NABH consultancy method: eligibility check, gap analysis, documentation, training, mock assessment, application and assessment support, with fees.
- Licences & registrationsClinical establishment registration, AERB, biomedical waste, fire NOC, PC-PNDT, drug licence, FSSAI and blood centre licences for hospitals.