NABH documents contain more than 160 editable MS-Word files. These editable documents address all the elements of hospital accreditation. You can buy NABH documents for your certification based on Standard.

  • A Manual
  • Required Procedures
  • Formats
  • Sample Filled Forms

Original price was: $900.00.Current price is: $749.00.



Our documentation kit (Technical file) contains sample documents required for CE certification as listed below. All documents are in MS Word files and you can edit them. You can make changes as per your organization’s need and within few days your entire Technical File with all necessary controls will be ready.

Content of NABH Documents for Hospital Accreditation as per 5th Edition

We had prepared the documentation for hospitals based on the NABH standard for hospital accreditation as per the 5th edition revised in April 2020. The NABH accreditation documents for hospital consists of the following:

  • Hospital Manual: A sample Hospital Manual which meets the NABH requirements for hospital accreditation. This includes vision and mission and hospital quality policy, organization structure, and macro-level system for compliance of hospital accreditation standards.
  • Department wise manual: The different department system is given in 5 departments wise manual as listed below.
  1. Infection control
  2. Emergency preparedness
  3. Medical record
  4. Human resources
  5. Central sterility supply department
  6. Bio Medical Manual.
  • System Procedures: We had prepared 8 system procedures to standardize the working in the hospitals and establish a systematic approach
  • Health and safety procedures: Total 9 health and safety procedures
  • Process approach for hospitals: More than 15 process approach
  • Standard operating procedures: Work instructions and SOPs for establishing a good hospital management system. We had prepared more than 75 standard operating procedures.
  • Forms and templates: Set of 64 standard forms and sample blank templates.
  • Hospital committee book: For 8 committee roles and responsibilities
  • NABH audit checklists: We are providing a set of over 700 audit questions, which can be customized to make your own NABH checklist for internal auditing of your hospital.


Our document kit is having sample documents required for implementation of NABH hospital accreditation as per latest National accreditation board of hospitals and healthcare provider standard (5th Edition April, 2020) for Accreditation standards for Hospital. The documents are prepared by the highly experienced team of people with rich experience of hospitals system establishment and process improvement and many hospitals are appraised successfully. You need to study it do necessary changes as per your company need and within 4 days your entire editable documents with all necessary details are ready as well as your team will got many ideas for system establishment to reduce the cost and effort with all necessary controls and your total documents are ready. We had given all type of templates and organization use it as per their need and many organization are certified globally in 1st trial with the help of our documents from any kind of stringent lead appraisal audit.
Under this directory further files are made in word document as per the details listed below. All the documents are related to NABH – Accreditation standards for Hospital for and user can edit it in line with their own processes.

1. Hospital Manual:

It covers sample copy of hospital manual details for NABH – Accreditation standards for Hospital is implemented. It covers Introduction, scope of service, hospital policy, vision and mission,
applicable laws and regulations, Quality policy and organization structure and covers 1st tier of NABH documents

Details of hospital manual

  1. Cover page
  2. Introduction
  3. Scope of services
  4. Hospital policies (Applicability of NABH Standards)
  5. Vision and Mission
  6. Applicable laws and regulation
  7. Quality Policy
  8. Organization structure

2. Department Manual:

It covers sample copy of department manual for NABH is implemented. It covers 5 department manual of NABH documents details given below

Details of department manual

  1. Central sterility supply department (CSSD) manual
  2. Emergency Preparedness Manual
  3. Infection control
  4. Medical Record
  5. Human Resource management (HR Manual )

3. System Procedures (08 Procedures):

It covers sample copy of system procedures covering all the specific practice areas of 08 processes. Our procedures help the organization to make the best system and quick process improvements. All procedures are divided in 08 system procedures as listed below.

List of system procedure

  1. Procedure for control of non–conforming services
  2. Procedure for management review
  3. Procedure for document and data control
  4. Procedure for corrective and preventive action
  5. Procedure for control of quality records
  6. Procedure for internal audit
  7. Procedure for control of monitoring and measuring equipments
  8. Procedure for Training

4. Health and Safety Procedures (09 Procedures):

It covers sample copy of health and safety procedures covering all the specific practice areas of 09 processes. Our procedures help the organization to make the best system and quick
process improvements. All procedures are divided in 09 system procedures as listed below.

List of health and safety procedure

  1. Procedure for hazards identification and risk assessment
  2. Procedure for identification of legal and other requirements
  3. Procedure for objectives and targets
  4. Procedure for OHSMP
  5. Procedure for consultation and communication
  6. Procedure for operational control
  7. Procedure for emergency preparedness and response
  8. Procedure for performance monitoring and measurement
  9. Procedure for incident investigation, non–conformity, corrective action and preventive action

5. Process Approach (16 System Process Approaches):

It covers sample copy of process approaches covering all the specific practice areas of 16 process approach. Our process approach helps the organization to make the best system and
quick process improvements. All process approach are divided in 16 system process as listed below

List of process Approach

  1. Billing Section
  2. Medical shop
  3. CATH Laboratory
  4. Client Service
  5. ECG Laboratory
  6. Engineering
  7. Human Resource Department
  8. Linen Activity
  9. Marketing
  10. X-Ray and Sonography Laboratory
  11. Utility
  12. Stores
  13. Purchase
  14. Pathology Laboratory
  15. Nursing Station
  16. Microbiology Laboratory

6. Standard operating procedures (89 SOPs):

It covers sample copy of SOPs covering Access, assessment and continuity care (AAC), Care of patient (COP), Facility Management and Safety (FMS), Human resource management (HRM),
Management of Medicine (MOM), Patient rights and education (PRE) and Patient safety and Quality improvement departments (PSQ). It covers all SOPs details list given below;

List of SOPs
Access, Assessment and Continuity of Care (AAC)

  1. Scope of services
  2. Registration
  3. Policy for Admission
  4. Filling the admission form
  5. Procedure during non availability of beds
  6. Laboratory safe practices
  7. Radiology services
  8. Admission of patient in ICU
  9. Assessment Policy
  10. Handling and disposal of radioactive wastes
  11. Discharge Procedure
  12. Patient Education on expected cost
  13. Transfer Policy

Care of Patient (COP) 

  1. Uniform care of patient
  2. Administration of Anesthesia
  3. Admission Criteria for ICU
  4. Ambulance services
  5. Bed Management in ICU
  6. Care of patient under Surgical Procedure
  7. Care of Vulnerable Patient
  8. Cardiac Pulmonary Resuscitation
  9. Criteria for Discharge of Patient
  10. Emergency care
  11. Handling of Medical Legal Cases
  12. End of Life Care
  13. Nutritional Assessment of Patient
  14. Pain Management
  15. Prevention on Adverse Event in Surgical Patient
  16. Quality Assurance Programme- Surgical Services
  17. Rationale use of Blood & Blood Products
  18. Rehabilitative Services
  19. Sedation
  20. Care of obstetrics Patient
  21. Organ Transplant Policy

Facility Management and Safety (FMS)

  1. Maintenance Activity
  2. Code Blue
  3. Code Pink
  4. Code Red
  5. Bio Medical Manual


  1. Casualty
  2. CCU Patient
  3. CTOT
  4. Dialysis
  5. Dressing and plaster
  6. EEG
  7. Endoscopy
  8. Enquiry
  9. Paediatric
  10. Gynac
  11. Physiotherapy
  12. ENT
  13. Kitchen
  14. Dental
  15. Ortho and Neuro OT
  16. Library
  17. Nursing Station
  18. Landry
  19. SICU
  20. Eye OT
  21. Security
  22. GOT
  23. Urology and Lithotripsy
  24. Plastic OT
  25. General Health Check Up

Human Resource Management (HRM)

  1. Performance Review and Appraisal Policy
  2. Employee Grievance policy

Management of Medication (MOM)

  1. Pharmacy Services
  2. Use of Radioactive and Investigational Drugs
  3. Disposal of Chemotherapeutic drugs
  4. Hospital Formulary
  5. Acquisition of medicines
  6. Prescription of medicines
  7. Dispensing of medication
  8. Medication administration
  9. Storage of medication
  10. Verbal order of medication
  11. Use of medical gases
  12. List of high risk medication
  13. Usage of Chemotherapeutic Agents
  14. Use of Implantable Prosthesis

Patient Rights and Education (PRE)

  1. Patient Rights
  2. Informed Consent
  3. Protection of patient rights
  4. List of condition required informed consent
  5. Communication

Safety and Quality Improvement (PSQ)

  1. Safety Programme
  2. Indicator Monitoring System
  3. Sentinel events and incident reporting
  4. Clinical Audit

7. Blank Formats (91 Formats):

It covers sample copy of forms required to maintain records in the hospital as well as establish control and make system in the organization. The samples given are as a guide and not compulsory to follow and hospitals are free to change the same to suit own requirements. The formats list given below;

List of Formats

  1. Sanitation audit report
  2. Breakdown History card
  3. Operative notes
  4. Pest control report
  5. Request for microbiological testing
  6. Purchase Order
  7. Fumigation report
  8. Room Check list
  9. Indent cum incoming inspection report
  10. Operation theatre readiness form
  11. Anti termite treatment
  12. Supplier Registration form
  13. Toilet Cleaning record
  14. Rodent Treatment
  15. Approved Vendor list
  16. Daily Equipment Cleaning record
  17. Cockroach Treatment
  18. Daily stock statement
  19. House keeping records
  20. R.O. Plant Log Sheet
  21. Gate pass
  22. Suggestion Card
  23. Operation theatre readiness report
  24. Preservation assessment Report
  25. Patient Complaint Report
  26. Emergency register
  27. Master list cum distribution list of documents
  28. Inquiry Monitoring record
  29. Patient Transfer Register
  30. Change Note
  31. List of chain pulley blocks, lifts ,pressure vessels etc
  32. Patient Registration form
  33. Calibration status of instruments
  34. Evaluation Of OHS Hazards and Risks
  35. Blood Transfusion and Adverse Effects Form
  36. Master list of records
  37. OHS Review Of Prioritization Of Significant OHS Hazards Its Risks Feasibility Analysis
  38. Blood Transfusion Patient Information and Consent
  39. Indoor file papers arrangement
  40. OHSMP Progress Monitoring Report
  41. High risk consent
  42. Audit schedule/plan
  43. Near Miss Report
  44. Anaesthesia Records
  45. Internal audit non conformity report
  46. Investigation Report
  47. Post Operative Monitoring
  48. Corrective Action report
  49. Safety Inspection Check List
  50. Pre Operative Checklist
  51. Preventive Action report
  52. Work Permit Report
  53. Surgical safety checklist
  54. Training calendar
  55. First aid box check list
  56. Nursing Notes
  57. Training need cum record sheet
  58. Fire fighting checklist
  59. Estimate Form
  60. Induction training report
  61. PPE Preventive Maintenance check points
  63. Job description and specification
  64. Location List of fire extinguisher
  65. Anaesthesia Consent Form
  66. Multi skill Index
  67. Fire hydrant checklist
  68. Discharge Summary
  69. Admission Check list
  70. Ambulance review checklist
  71. Crash Cart / Emergency Medicine Check List
  72. Discharge Check list
  73. Earthing pit test report
  74. Autoclave Register
  75. Checklist for personal file
  76. Disposal of non confirming work
  78. Employee Training sheet
  79. Sterilization report
  80. Patient assessment & Plan of Care
  81. Credentialing and privileging of medical professional
  82. DG Set monitoring report
  83. MLC form
  84. Steam Boiler Monitoring report
  85. Vaccination records
  86. Incineration plant report
  87. MRD Register
  88. Narcotics Drug Register
  89. Preventive maintenance schedule
  90. Credentialing and privileging of Nursing and allied staff
  91. Medication Administration Report

8. Hospital committee:

This gives the list of all 8 committees and formation of committee and functions and guidelines for the committee.

List of committees

  1. Quality Improvement Committee
  2. Infection Control Committee
  3. Pharmaco- Therapeutic Committee
  4. Medical Audit Committee
  5. Safety Committee
  6. Grievance Re-dressal Committee
  7. Disaster Preparedness Committee
  8. Ethics Committee

9. Audit checklist (more than 700 questions)

There covers audit questions to be used for hospital system auditing for objectively evaluate the adherence of system by functional heads to establish processes. It also includes audit questions
as a quick reference for all related work areas of the hospital. Total more than 250 audit questions gives better understanding to the process owners as well as to the auditors to establish good
system and process discipline in hospital as well as for each department. It will be very good tool for the auditors to make audit questionnaire while auditing and make effectiveness in auditing in the hospital.

10. Compliance matrix

This compliance matrix contains NABH – Accreditation standards for hospital and healthcare providers clause wise list of documented information for easy reference of users and to
understand how this system is made.

How useful?

  • The user can modify the templates as per their working system and create own NABH documents for their hospital.
  • Readymade templates are available which can reduce your time in document preparation as well as training to staff and for NABH hospital manual preparation.
  • Procedures and formats provided in document kit can help in fine-tuning the processes and establish better control and excellent system in the hospital for better management and patient care.
  • It saves a lot of time and cost in document preparation. It gives value for money to customers and payback is very low.
  • Takes care for all the sections and sub-sections of the NABH standard and gives better confidence as well as improve the system.


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