Skip to content

NABH Gap Assessment

LicencesS.noLiscence namePresent or not /NALicence NoIssuing authorityValid FromValid Upto
CHospital Registration
DBio medical waste
EAerb- C-arm
FAerb- Ct
GAerb- X-ray (mobile)
HAerb -X-ray(fixed)
IAerb- X-ray (dental)
jShop and establishment
KPharmacy Licence
LNarcotics Licence
MOUS.noMOU namePresent or not /NAOn Stamp Paper Yes/ NoMOU withValid FromValid Upto
DBio medical waste
ELinen and laundary
FPharmacy Licence
IBlood bank
jEye bank
KPest control
2FilesS.noDocumentsPresent or not /NARemarks
1Doctors Plan of care
2Initial Assessment by doctors
3Bilingual Consents with Risk, Benfits and Patient and doctor signature
4Nursing Initial assessment
5Vitals, Input and output, Blood sugar and investigation monitoring
6Treatment chart- With dose, frequency, route, time and signature
7Pre- aneasthesia notes
8Aneasthesia notes
9OT notes
10Post aneasthesia notes
3 infrastructureS.noDocumentsPresent or not /NARemarks
1Grab rails in washrooms
2Hand rails at stair case
3OT zoning (uniflow)
4CSSD zoning (uniflow)
5Approach to Emergency is clear and unobstructed
6Ramp if present has anti skid tiles
7Nursing call bell at nusring stations
8Bio medical waste room is under lock and key with seprate dustbins
9Gas manifold is caged and cylinders are secured with chains
10Elbow taps on washbasins
11Hospital Curtains – Fibre made
12Pedal operated Dustbins
13Bilingual Signages
14Fire escape route signages
15Fire exit signages
16patient right’s and responsibility
17Scope of services signages
18PCPNDT signages
19Radiation signages
20Fire extinghuishers
21Fire Detectors and fire alarm
22Sand Buckets for DG sets
23Insulated Mats for DG and LT panel
24Lead sheet for OT and Radiology Doors
25Temerature meter for fridge
25Temoerature and humidity meter for OT and ICU pharmacy
4. MOMS.noDocumentsPresent or not /NARemarks
1Multidose vials are lablled for date of opening
2consumables are lablled for date of opening and date of expiry
3look alike and sound Alike drugs ar seprated
4High Risk Drugs are listed
5Departments have access to emergency drugs
6Intubation tray is present in ICU/ OT/ ER
7Injection and cannula tray I present
8Inventory registrors are present
9Sterilized objects have Date of autoclaving and load number on them
10Sterilization Indicators- Bowie dick, Chemical and biological indicators are used.
11Hand rubs and hand wash liquids are used
5. ManpowerS.noDocumentsPresent or not /NARemarks
1MBBS doctors Number : With Registration Number
2Consultants Number: With Registration Number
3Non MBBS Number
4GNM Number : With Registration Number
5Anm Number
6Technician Number
7OT Technician
8Dialysis Technician
9Radiology Technician
10Lab Technician
11Non Eligible Staff Number
12BME incharge
13HR person
14MRD person
15Quality person
16FMS person
17HIC nurse
6.ProcessS.noDocumentsPresent or not /NARemarks
1Registration Process is there or not For OP And IP
2UHID generation Or not
3Hims Using or not
4mission and vision of the hospital
5TLD Batches for radiographer
6TLD batches for OT technicians
7TLD batches for Surgeon and anesthetic