NABH readiness — what an assessor will ask for

Read this first

NABH has not seen this page and it is not NABH guidance. It is a preparation list, written as the questions an assessor asks — “show me” — because that is the only form a hospital can act on in the weeks before an assessment.

References stop at the chapter — AAC, COP, MOM, PRE, HIC, PSQ, HRM, IMS, FMS. Standard and objective-element numbers are deliberately not reproduced: they renumber between editions, and a number quoted from memory on a public page is worse than no number at all. Check every line against the edition your assessment runs under.

The half this page can be exact about is where the evidence already exists as a row somebody wrote in the course of the work, rather than as a file somebody has to assemble in the fortnight before the visit. That difference is the whole of the preparation problem.

AAC — how a patient gets in, gets assessed, moves between units, and gets out.

• Does every patient have one identifier that follows them, with no duplicate records for the same person?MedAppz does this

  Two records for one patient is the failure everything downstream inherits — the allergy on the other file, the result nobody saw.Matching runs across spelling, phonetics and Devanagari transliteration before the save, and a strong match has to be resolved by a person — the system will not auto-merge however confident it is. Merges are reversible and logged, and the numbering is gapless, so a failed save releases the number instead of burning it. See the app →

  NABH — AAC chapterYesNoNot sure
• Is the initial assessment documented within the time your own policy states, and reassessment on schedule after that?MedAppz gives you the desk

  The assessor reads your policy first and then looks for records that match it.Clinical entries carry the time and the author and cannot be edited in place afterwards, so “when was this written” is answerable. The interval your policy sets is yours to state and yours to keep. See the app →

  NABH — AAC chapterYesNoNot sure
• Is handover between shifts structured, and do the open tasks travel with it?MedAppz does this

  Most inpatient harm happens across a handover, and “I told the night sister” is not a record.Handover is written per patient in SBAR — situation, background, assessment, recommendation — with open tasks attached to the entry, so nothing is handed over by being forgotten. See the app →

  NABH — AAC chapterYesNoNot sure
• Does every discharge follow a documented process, and does the patient leave with a summary?MedAppz does this

  The discharge summary is the single document the next doctor will read.The discharge runs as a checklist — medicines, summary, bills, transport — with the blocking item visible, and the gate pass is refused while a blocking item is open. The discharge summary is one of the documents the product draws. See the app →

  NABH — AAC chapterYesNoNot sure

COP — orders, resuscitation, surgery, and the high-risk areas that get their own visit.

• Are orders written, attributable, and acknowledged by the nurse who will act on them?MedAppz does this

  An order nobody acknowledged is an order nobody owns.The inpatient order sheet holds drug, investigation, diet, nursing, activity, consult and monitoring orders. A nurse acknowledgement is what makes an order actionable, and the prescriber cannot acknowledge their own — the database derives the prescriber from the session rather than taking it from the request, so the rule cannot be walked around. See the app →

  NABH — COP chapterYesNoNot sure
• Are verbal and telephone orders countersigned within your stated window?MedAppz does this

  Verbal-order culture is where wrong-drug events start, which is why this one is always looked at.A verbal order is recorded as one and needs a countersignature from somebody other than the person who wrote it down. The nurse taking the call is the one who can enter it. See the app →

  NABH — COP chapterYesNoNot sure
• Are resuscitations recorded with real times, and are the crash carts checked?MedAppz does this

  A code record written up afterwards from memory is the one thing a reviewer can always tell.Compressions, shocks with the energy delivered, drugs and the airway are one tap each and stamped when tapped; a late entry is marked late rather than dressed as live. Cart checks refuse “incomplete” until somebody says what is missing. See the app →

  NABH — COP chapterYesNoNot sure
• Is the surgical safety checklist completed before every procedure, not signed afterwards in a batch?MedAppz does this

  A checklist filled in at the end of the list is worse than none, because it looks like evidence.Sign-in, time-out and sign-out are three stamps in order, and the buttons only offer what the checklist allows: a case cannot enter theatre without the first or complete without the last. See the app →

  NABH — COP chapterYesNoNot sure
• Are swab and instrument counts recorded, and does a mismatch stop the closure?MedAppz does this

  The retained item is the never-event every accreditation body asks about by name.Counts in and out are rows on a sheet. Where they disagree the sheet escalates to a discrepancy carrying what was done — recount, field check, imaging — and it does not close until every item reconciles and every discrepancy is resolved. See the app →

  NABH — COP chapterYesNoNot sure
• Is there an anaesthesia record from pre-anaesthetic assessment through to recovery discharge?MedAppz does this

  The pre-op assessment and the recovery score are the two ends assessors check for.One record per case, carrying the airway assessment, the technique and the agents. It will not sign without an ASA grade, a technique and a confirmed fasting status, and nobody leaves recovery without an Aldrete of 9 or better already on the record — both are refusals in the database rather than reminders on a screen. Signing turns it into a document rather than a page that can still be tidied. See the app →

  NABH — COP chapterYesNoNot sure

MOM — prescribing, checking, administering, and the drugs that need permission.

• Is a prescription checked against the patient’s allergies and against the other drugs on it?MedAppz does this

  The allergy on the chart that nobody saw is the classic medication event.Allergies recorded on the chart drive the prescribing gate automatically, and the interaction check compares the drugs on the same prescription with each other, not only against what was already running. See the app →

  NABH — MOM chapterYesNoNot sure
• Is administration recorded at the time, against the order?MedAppz does this

  A drug chart signed in a block at the end of a shift proves the shift ended, nothing else.Scan the patient, scan the drug: the dose does not record as given until both barcodes have matched this entry, and the time on it is the database’s own clock at the moment it is recorded — never a time typed by the person charting, so a round written up at the end of a shift cannot be made to read as punctual. An omission carries its reason, a controlled drug needs a co-signature from a second named person, and an order that has been stopped omits its remaining doses rather than leaving them sitting due. See the app →

  NABH — MOM chapterYesNoNot sure
• Do restricted antimicrobials need approval, and does every course have a stop-or-review date?MedAppz does this

  Antimicrobial stewardship is a programme, not a poster, and it is asked about as one.A restricted drug generates an approval request with its indication, approved or declined with a reason. Every course carries the date it is reviewed or stopped, and a culture result puts the narrower option beside the running one. See the app →

  NABH — MOM chapterYesNoNot sure
• Does your antibiogram come from your own isolates?MedAppz does this

  A stewardship programme reading somebody else’s sensitivities is guessing politely.Culture, growth, organism and the sensitivity grid are recorded as the bench works, and the verified isolates are what the unit antibiogram is built from. See the app →

  NABH — MOM chapterYesNoNot sure

PRE — consent, price, and what happens when somebody complains.

• Is informed consent procedure-specific, with the risks named, in a language the patient reads?MedAppz gives you the desk

  A generic all-risks form is the one an assessor and a court both dismiss.A form is drafted per procedure and per language at a reading level you pick, and the risks in it are yours to write — MedAppz ships no library of procedure risks and will not pretend to hold one. What it does refuse is a consent taken without a teach-back answer in the patient’s own words, or an interpreter claimed without a name. Publishing is one-way, so the version somebody signed is still readable years later, with the language used, the minutes spent and who explained it on the same row. See the app →

  NABH — PRE chapterYesNoNot sure
• Can a patient see what a procedure or a package costs before they are admitted?MedAppz does this

  Price transparency is both an accreditation question and the commonest cause of a discharge argument.The price list is published from the tariff that bills, at the rate effective when it is imported and stamped with that date, and one link and one wall code carry it — a clinic has one published list at a time, and publishing freezes it so it cannot change under somebody reading it. An estimate is different: every line on it is resolved live through the billing engine, and it expires rather than being quietly honoured at an old price. See the app →

  NABH — PRE chapterYesNoNot sure
• Does every complaint have an owner, a clock, and a closure the complainant actually heard?MedAppz does this

  Closing a complaint on an internal note is the finding, every time.A grievance is logged with an owner and a clock, escalates before the deadline rather than after, and cannot be closed until the response has reached the person who complained. See the app →

  NABH — PRE chapterYesNoNot sure

HIC — surveillance with real denominators, and what happens when two isolates look related.

• Are your infection rates computed from real device-days rather than an estimate?MedAppz does this

  A rate with an invented denominator is a number that will not survive being asked how it was made.Device-days are entered as data, and with none there is no rate — the page says so instead of dividing by a guess. Bundle audits require “what was missed” on anything that failed. See the app →

  NABH — HIC chapterYesNoNot sure
• Is there a line list when linked cases appear, and is it kept honestly?MedAppz does this

  An outbreak line list that shrinks is the one thing worse than an outbreak.Declaring an outbreak opens a line list that is append-only: a case is added and linked, never quietly removed once the numbers get awkward. See the app →

  NABH — HIC chapterYesNoNot sure
• Is biomedical waste segregated, weighed and handed over with a record?MedAppz gives you the desk

  This one is checked physically, on the day, at the bins.The registers, the categories and the handover records are held in the product. The segregation itself happens at the bin, and no software will do it for you. See the app →

  NABH — HIC chapterYesNoNot sure

PSQ — incidents, mortality review, indicators and drills: the loop that has to close.

• Can staff report an incident without fear, and does the report lead to an action that is finished?MedAppz does this

  An incident register with no closed corrective actions is a filing habit, not a safety system.A report takes two minutes and can be anonymous — no reporter is stored on an anonymous report. Closing is a gate: a root-cause analysis on the record and every corrective action done with an owner and a due date, or the incident stays open. See the app →

  NABH — PSQ chapterYesNoNot sure
• Is every death reviewed, and does the review produce a learning point somebody can find later?MedAppz does this

  The meeting is easy to hold and hard to evidence. The learning is what an assessor asks to see.The case timeline is reconstructed from the record — orders, vitals, notes — rather than from memory, and a case does not close without a verdict and at least one learning point. A meeting does not close while a case on it has no verdict. See the app →

  NABH — PSQ chapterYesNoNot sure
• Are quality indicators collected on a schedule and trended, rather than assembled for the assessment?MedAppz does this

  A year of numbers produced in a fortnight looks exactly like a year of numbers produced in a fortnight.Indicators are computed from the record as the work happens — door-to-doctor, prescribing overrides, outcome trends — so the trend exists before anybody asks for it. See the app →

  NABH — PSQ chapterYesNoNot sure
• Are mock drills held, and is what went wrong in them written down?MedAppz gives you the desk

  A drill with a perfect outcome every time is a drill nobody is grading.Drills are scheduled and recorded with their findings. Holding one that actually tests something is the hospital’s job. See the app →

  NABH — PSQ chapterYesNoNot sure
• Do the committees meet, and do their minutes carry actions that get closed?MedAppz gives you the desk

  Minutes without actions are the most common thing on a quality shelf.Agendas, quorum, decisions and the actions arising with deadlines that escalate. An inquorate meeting’s decision is not recorded as approved. Your SOPs sit beside them with owners, review dates and who has acknowledged which version. Turning up is yours. See the app →

  NABH — PSQ chapterYesNoNot sure

HRM — who is allowed to do what, and whether their paperwork is current.

• Is every clinician’s registration verified and current, and do you find out before it lapses?MedAppz does this

  A lapsed registration discovered by an assessor is a different conversation from one discovered by you.Registrations and cards are held with their expiry dates and announce themselves before they run out, instead of lapsing quietly in a file. See the app →

  NABH — HRM chapterYesNoNot sure
• Are clinical privileges granted per procedure — and honoured when the list is being booked?MedAppz does this

  A privileging file that the operating list never consults is a document, not a control.Privileges are recorded per procedure with evidence and an expiry, and the theatre list reads them: booking a declared procedure needs a surgeon the register can check, and the server refuses one it cannot — it does not trust the screen to send the right code. See the app →

  NABH — HRM chapterYesNoNot sure
• Can you show who has had which training, and who is overdue?MedAppz gives you the desk

  Induction, fire, BLS, infection control — asked for by name and by person.Training requirements are held per role with who has completed what and who is overdue. Running the session is yours. See the app →

  NABH — HRM chapterYesNoNot sure

IMS — the record, who may read it, how long it is kept, and whether the backup has ever been restored.

• Is every entry in the record attributable, timed, and impossible to alter without it showing?MedAppz does this

  A record that can be tidied is a record that will be assumed to have been.A signed clinical entry is amended, never edited — the database refuses an in-place change — so a correction appends with its own name and time and the original stays readable. See the app →

  NABH — IMS chapterYesNoNot sure
• Is access to records controlled by role and logged — including the emergency access?MedAppz does this

  It is the line every IT committee reads first, and “everybody shares one login” is the answer that ends the conversation.Row-level security the application account cannot switch off, a permission on every screen and every write, and a hash-chained log of opens, searches and exports that is re-verified nightly. Emergency access expires and is flagged for review rather than lasting until somebody notices. See the app →

  NABH — IMS chapterYesNoNot sure
• Are records retained for your stated period and disposed of with a record of the disposal?MedAppz gives you the desk

  Both halves are asked for: the period, and the certificate for what went.Retention is stored with the basis you are relying on, destruction runs against an approved proposal and produces a certificate, and a legal hold stops it. MedAppz ships no periods — you state yours and cite your source, and the product quotes your citation back. See the app →

  NABH — IMS chapterYesNoNot sure
• Do requests for a copy of a record — patient, insurer, police, court — follow one process with a time limit?MedAppz does this

  The medico-legal copy request is where a records department is judged.The records desk takes the request, names who asked and in what capacity, and runs a seventy-two-hour clock on it, separately from the statutory privacy request which has its own clock and its own desk. See the app →

  NABH — IMS chapterYesNoNot sure
• Is there a backup, and has anybody ever restored from it?MedAppz gives you the desk

  An untested backup is a belief. This line is asked as “show me the restore”.MedAppz backs up nightly, verifies the dump, and rehearses the restore. Being straight about the rest: those backups are not yet held off-site or encrypted at rest, and the trust centre says so — take that to your committee rather than from this line. See the app →

  NABH — IMS chapterYesNoNot sure
• Is your standard-by-standard evidence current, or assembled the month before the assessment?MedAppz gives you the desk

  The gap between a policy and the log that proves it was followed is where an assessment is actually lost.Standards are mapped to living evidence — policies, logs, audits — with staleness flagged before an assessor finds it. It will not fabricate evidence: a gap stays a gap until it is closed. See the app →

  NABH — IMS chapterYesNoNot sure

FMS — the chapter that is mostly outside any software, with two lines that are not.

• Is every piece of equipment inventoried, with its service and calibration history?MedAppz gives you the desk

  The sticker on the machine and the register have to agree.Assets are held with their service schedules and calibration records, and machine logs sit against the equipment they belong to. The engineer still has to turn up. See the app →

  NABH — FMS chapterYesNoNot sure
• Are your statutory licences current, and does somebody find out before one expires?MedAppz gives you the desk

  An expired licence found on the day is the fastest way to fail an assessment.Registration certificates, the mandated display list, the minimum-standard checklists and the renewal timelines are held with their evidence attached. “Displayed” is a claim somebody has to verify against their name before the row will take it, and “not applicable” will not save without a reason. Radiation licences, badge cycles and QA calendars have their own register. Which licences your facility needs is still a question for your own list. See the app →

  NABH — FMS chapterYesNoNot sure

What this does not do

Chapter abbreviations follow NABH’s hospital standards, but standard and objective-element numbers change between editions and are not reproduced here. Check every line against the edition your assessment runs under. This page is a preparation aid; it is not NABH guidance and nobody at NABH has seen it.