NABH Gap Assessment - Jyoti Hospital

Licences	S.no	Liscence name	Present or not /NA	Licence No	Issuing authority	Valid From	Valid Upto
	A	MTP
B	PNDT
C	Hospital Registration
D	Bio medical waste
E	Aerb- C-arm
F	Aerb- Ct
G	Aerb- X-ray (mobile)
H	Aerb -X-ray(fixed)
I	Aerb- X-ray (dental)
j	Shop and establishment
K	Pharmacy Licence
L	Narcotics Licence
MOU	S.no	MOU name	Present or not /NA	On Stamp Paper Yes/ No	MOU with	Valid From	Valid Upto
	A	Ambulance
B	Radiology
C	Laboratory
D	Bio medical waste
E	Linen and laundary
F	Pharmacy Licence
G	Physiotherapy
H	Kitchen
I	Blood bank
j	Eye bank
K	Pest control
L	Security
		m	Housekeeping
2	Files	S.no	Documents	Present or not /NA	Remarks
	1	Doctors Plan of care
2	Initial Assessment by doctors
3	Bilingual Consents with Risk, Benfits and Patient and doctor signature
4	Nursing Initial assessment
5	Vitals, Input and output, Blood sugar and investigation monitoring
6	Treatment chart- With dose, frequency, route, time and signature
7	Pre- aneasthesia notes
8	Aneasthesia notes
9	OT notes
10	Post aneasthesia notes
3 infrastructure	S.no	Documents	Present or not /NA	Remarks
	1	Grab rails in washrooms
2	Hand rails at stair case
3	OT zoning (uniflow)
4	CSSD zoning (uniflow)
5	Approach to Emergency is clear and unobstructed
6	Ramp if present has anti skid tiles
7	Nursing call bell at nusring stations
8	Bio medical waste room is under lock and key with seprate dustbins
9	Gas manifold is caged and cylinders are secured with chains
10	Elbow taps on washbasins
11	Hospital Curtains – Fibre made
12	Pedal operated Dustbins
13	Bilingual Signages
14	Fire escape route signages
15	Fire exit signages
16	patient right’s and responsibility
17	Scope of services signages
18	PCPNDT signages
19	Radiation signages
20	Fire extinghuishers
21	Fire Detectors and fire alarm
22	Sand Buckets for DG sets
23	Insulated Mats for DG and LT panel
24	Lead sheet for OT and Radiology Doors
25	Temerature meter for fridge
25	Temoerature and humidity meter for OT and ICU pharmacy
4. MOM	S.no	Documents	Present or not /NA	Remarks
	1	Multidose vials are lablled for date of opening
2	consumables are lablled for date of opening and date of expiry
3	look alike and sound Alike drugs ar seprated
4	High Risk Drugs are listed
5	Departments have access to emergency drugs
6	Intubation tray is present in ICU/ OT/ ER
7	Injection and cannula tray I present
8	Inventory registrors are present
9	Sterilized objects have Date of autoclaving and load number on them
10	Sterilization Indicators- Bowie dick, Chemical and biological indicators are used.
11	Hand rubs and hand wash liquids are used
5. Manpower	S.no	Documents	Present or not /NA	Remarks
	1	MBBS doctors Number : With Registration Number
2	Consultants Number: With Registration Number
3	Non MBBS Number
4	GNM Number : With Registration Number
5	Anm Number
6	Technician Number
7	OT Technician
8	Dialysis Technician
9	Radiology Technician
10	Lab Technician
11	Non Eligible Staff Number
12	BME incharge
13	HR person
14	MRD person
15	Quality person
16	FMS person
17	HIC nurse
6.Process	S.no	Documents	Present or not /NA	Remarks
	1	Registration Process is there or not For OP And IP
2	UHID generation Or not
3	Hims Using or not
4	mission and vision of the hospital
5	TLD Batches for radiographer
6	TLD batches for OT technicians
7	TLD batches for Surgeon and anesthetic

Share this:

Like this:

Trending now