NALAM HOSPITAL - NABH ELIGIBILITY

Date: 27/06/2022
S.NO REQUIREMENTS REMARKS
1.         30% Occupancy Rate 20beds 

2.         Generate UHID Yes

3.         Hospital Registration License - Ownership License Yet to be verified

4.         Clinical Establishment Act Registration Yes - 10beds

5.         Pharmacy Yes

6.         Scan - PCPNDT Yes

7.         Fire  -NOC/License No (renewal is missed)

8.         Pollution Control Board- BMWM Yes - 10 beds

9.         Air Clearance – PCB Yes - 20 beds

10.     Water Clearance – PCB Yes - 20 beds

11.     AERB – X-ray NA
12.     Narcotics - NDRC No - optional
13.     DL2 License - Spirit License No - optional
14 MTP License
15 Lift License No - optional
16 MOU for Outsourced services
·         Ambulance Need to arrange
·         Lab 
·          Scan
·         X-ray  
·         CT
·         MRI
·         Blood bank
·         Referral Hospital
17 SIGNAGE: Intiated, few under 
·         Fire safety - radium exit sign process.
·         Fire Safety -directional sign (arrows)
·         Fire Safety - extinguisher - PASS
·         Fire Safety - escape route plan
·         Fire Safety - ramp signage
·         Fire Safety - hydrant signage
·         Biomedical waste segregation
·         Bio Hazard
·         Pt Rightsand responsibility
 ·          Floor plan – escape route
·         Pt . information signage
·         Educational posters.
·         CODES  - contact number 
·         CODES  - process
·         Hospital ownership
·         Scope of services
·         Traiff
·         Pediatric scope of service
·         OBG scope of service
·         How to voice a complaint
·         Entry restriction
·         Directional signage
·         Floor Directory
·         No smoking
·         Visiting time
·         Electrical safety
·         Internal signages
18 Department Training Under process
·            Nursing
·         Laboratory Safety
·         X-ray safety
·         HIC
·         House Keeping
·         Safety Training
·         CODES
·         HR
·         Hospital policies and protocols.
19 Case sheet
·         Admission consent available
·         Surgery consent available
·         Anaesthesia  consent available
·         High risk consent available
·         Blood transfusion consent
·         Admission form available
·         Care plan - doctors initial assessment available
·         Doctors progress notes available
·         Drug chart - orders available
·         Drug chart - Administration available
·         NSG initial assessment
·         Monitoring chart available
·         Pre op checklist no
·         Operation notes no
·         Post operative orders no
·         PAC and Immediate anaestheia checklist no
·         Intra op monitoring no
·         Post Op and recovery criteria no
 ·         Blood transfusion form - monitoring no
·         Monitoring chart no
·         ICU monitoring chart NA
·         ICU consent NA
Diagnostics
·         Nominal Register available
·         Critical Values docuementation lab- available
·         QC no
·         Indicators no
·         TAT no
·         Displays - warning sign no
·         PCPNDT signage yes
20 ·         AERB signage Yes
21 ·         TLD badge Yes - 1
22 ·         Lead apron screening No
23 ·         Thyroid collar Yes
24 MLC register No
25 Transfer out register No
26 AR copy and Police intimation records Yes
27 Wound certificates Yes
28 Death register Yes
29 Birth register Yes
30 IUCD registers Yes
31 Scan Register Yes
32 MTP Register Yes
33 OT register Yes
34 IP Register Yes
35 Nominal – Diagnostic services Yes
36 Narcotics stock and usage register No