This presentation contains the summary of documentation which is important as per standards of national accreditation board for hospital and healthcare providers.

1. B Y – A B H I S H E K S R I V A S T A V A
B H M , M H A
Documentation required for Treating
Consultant / Physician as per National
Accreditation Board for Hospitals & Healthcare
Providers

2. Chapters of NABH 4th Edition
1. AAC – Access Assessment and Continuity of Care
2. COP – Care of Patients
3. MOM - Management of Medication
4. PRE – Patient Rights and Education
5. HIC – Hospital Infection Control
6. CQI – Continuous Quality Improvement
7. ROM – Responsibility of Management
8. FMS – Facility Management and Safety
9. HRM – Human Resource Management
10. IMS – Information Management System
PatientCenteredOrganizationCentered

3. Chapters of NABH 4th Edition
1. AAC – Access Assessment and Continuity of Care
2. COP – Care of Patients
3. MOM - Management of Medication
4. PRE – Patient Rights and Education
5. HIC – Hospital Infection Control
6. CQI – Continuous Quality Improvement
7. ROM – Responsibility of Management
8. FMS – Facility Management and Safety
9. HRM – Human Resource Management
10. IMS – Information Management System
PatientCenteredOrganizationCentered

4. AAC – Access Assessment and Continuity of
Care
 Initial Assessment and Care Plan.
 Documented Assessment – Every Patient every day
until the discharge
 Notes should Include – Current Status of patient,
Detailed assessment, Medications, Critical Results if
any

5. COP – Care of Patient
 Uniform Care Policy
 Standard Treatment Protocol
 Daily Doctor’s Assessment
 Referral of patient documentation
 Informed Consent for every procedure
 Consents should include the information about the risk &
benefits, alternatives of treatment and risk & benefits of doing
nothing.
 Infection Control Measures
 Patient Safety Measures
 Rational Use of Blood and Blood Product
 Identification and Reporting of community emergency and
epidemics

6. MOM – Management of
Medication
 Monitoring of patient under anaesthesia
 Discharge criteria from recovery area
 Surgical Patient - Planned Surgery
 Assurance of surgical procedures
 Nutritional Screening
 Monitoring of patient after medication administration
(Including Anaesthesia)
 Reporting of medication error
 Documentation of narcotics drug and psychotropic
medications
 Use of Implantable prosthesis
 Verbal Orders

7. PRE – Patient Rights and
Education
 Effective Communication & Documentation of same
with patient and family
 Patient Complaints escalation to operations or
patient welfare department

8. HIC – Hospital Infection
Control
 Rational use of antibiotics
 To make strong grip over antibiotics usage among
patients, quality department will introduce antibiotic
justification forms to prevent the irrational and over
use of antibiotics

9. CQI – Continues Quality
Improvement
 Quality Indicators
1. Time of Initial Assessment by doctors
2. Percentage of cases wherin care plan with desired outcome documented
and signed
3. Percentage of Medication Errors
4. Percentage of admission with adverse drug reaction
5. Percentage of medication chart with error prone abreviations
6. Percentage of patients receiving high risk medications developing
Adverse Drug Reactions
7. Percentage of modification of anaesthesia plan
8. Percentage of unplanned ventilation following anaesthesia
9. Percentage of Adverse anaesthesia event
10. Anaesthesia related mortality rate
11. Percentage of unplanned return to OT
12. Percentage of resheduling of OT

10. CQI – Continues Quality
Improvement
1. Percentage of adherence to surgical safety checklist
2. Percentage of cases who received appropriate prophylactic
antibiotic within specified time
3. Re- Exploration Rate
4. Percentage of Transfusion Reaction
5. Mortality Rate
6. Return to ICU within 48 Hours
7. Return to Emergency within 72 hour with similar presenting
complaints
8. Re-Intubation Rate
9. Incidence of Fall
10. Average Length of Stay
11. Percentage of medical records not having discharge summary