Sunday, 3 June 2012

Documentation basics for NABH implementation

One thing that keeps hospitals and NABH consultants on their toes is the documentation of policies, processes and SOPs (standard operating procedures). Many times hospitals would engage consultants only to get the documentation work done. Funny, isn’t it?

Do not worry because in this post, we are going to cover some basic aspects of documentation around NABH. To do that, firstly we need to understand what purpose is being served by documentation?

A documented policy, process and procedure becomes a single source of truth in an organizational set-up. The management, the other managers and head-of-departments and senior and junior employees have their own perspectives on how the care has to be delivered. These perspectives may not be in consonance with each other. The single source of truth, or the documentation, serves as a point of reference for everyone in the organization. While their personal perspectives may be respected, the documented system and processes have to be complied with consistently in the organization by everyone.

Coming on to the documentation basics, first you need to identify all standards/objective elements which require mandatory documentation. The NABH book of second edition had a list of documentation required under previous edition. Unfortunately the new one doesn’t have it, but you can still surf through the standards and you will get an idea. In the next step, you should prepare a list of processes and policies you need to document as part of mandatory requirement. You would realize you already have some existing documentation, and you may only need to tweak it a little bit.

When you create a document, ensure that:
  • You give a document-code to each document. The code can have a nomenclature which may indicate the department for which the document is applicable, the standard that this documented process is addressing and a few other details.
  • The issuing date of the document. A recent date would indicate that either the process is new or some changes were made in it recently.
  • Have an objective for each policy/process/procedure.
  • If you are documenting a process, define their start and end-points to avoid overlap.
  • If you are documenting a policy, define the scope of the policy.
  • Do cross-referencing of documentation wherever required for brevity.
  • After defining the document scope, also list down the responsible position. For example, a document regarding security of the facility will have security officer or in-charge as the responsible person. Avoid putting any names in this field because responsibility has to be mapped to a designation or position and not to an individual. Individuals may change over time.
  • Provide in detail the processes and policies. You can also use flow-charts and responsibility matrix to provide an overall view of the process.
  • Try to cover all aspects of the policy/process as defined in the scope of the document.
  • At the end, provide the names of the individuals who prepared, reviewed and approved the document. If required, you may skip the reviewer name.

The points above describe the basic steps that need to be followed to prepare your documentation. But ensure that you have taken inputs from other experts and colleagues on the content of each document.

For the cosmetic part of the documents, like where to place different information inside the document, colour schemes, branding etc. you can pick a format from an already accreditated hospital. 


  1. 3rd edition also has the list of documentation. it's 161 including all chapters.

    1. Thanks Parul for your reply and the information. Great to see you on blogger. Finally you have arrived. I hope the readers of this blog can benefit from your experiences too. Will wait for your call.