Anaesthesia Department Checklist for NABH Accreditation

1. General Requirements:
Qualified Anaesthetists:
Anaesthesia services should be provided by qualified anaesthetists only.
Yes No NA
The hospital's credentialing and privileging policy must specify the names of doctors authorized to
administer various anaesthesia types.
Yes No NA
Technicians are not permitted to administer anaesthesia.
Yes No NA
Informed Consent:
A separate informed consent for anaesthesia must be obtained from the patient, distinct from the
surgery consent.
Yes No NA
The consent form should specify the risks, benefits, and alternatives of anaesthesia.
Yes No NA

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The anaesthetist should explain the information clearly and answer any questions the patient may
have.
Yes No NA
Documentation:
For each patient requiring anaesthesia, the following documentation must be completed before
administration:
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Indications for anaesthesia: The reason for anaesthesia.
Yes No NA
Type of anaesthesia: The specific type of anaesthesia to be administered.
Yes No NA
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Procedure or method of administering anaesthesia: The technique used for anaesthesia
administration.
Yes No NA
Documentation should be clear, concise, and legible.
Yes No NA
Records should be maintained for a minimum of three years.
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Yes No NA
Pre-anaesthesia Assessment:
A pre-anaesthesia assessment should be performed by a qualified anaesthetist for every patient
requiring anaesthesia.
Yes No NA
The assessment should include:
Patient's medical history.
Yes No NA
Physical examination.
Yes No NA
Laboratory investigations.
Yes No NA
Imaging studies (if necessary).
Yes No NA
Assessment of risk factors for anaesthesia complications.
Yes No NA
Based on the assessment, the anaesthetist should determine the most appropriate type of anaesthesia
and develop a personalized anaesthetic plan.
Yes No NA
The plan should be documented and communicated to all healthcare professionals involved in the
patient's care.
Yes No NA
Monitoring:
During anaesthesia, the patient's vital signs should be monitored continuously.
Yes No NA
Monitoring should include:
Post-anaesthesia Care:
Following anaesthesia, patients should be monitored closely in a recovery area.
Yes No NA
The anaesthetist should ensure that the patient is stable and recovering well before discharge.
Yes No NA
Post-operative pain management should be provided.
Yes No NA
Patients should be provided with clear instructions for post-anaesthesia care.
Yes No NA
Emergency Preparedness:
The anaesthetic department should have a plan for managing emergencies that may arise during

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anaesthesia.
Yes No NA
The plan should include:
Emergency medications and equipment readily available.
Yes No NA
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Trained personnel to respond to emergencies.
Yes No NA
Protocols for managing specific emergencies.
Yes No NA
Regular drills should be conducted to ensure staff are familiar with the emergency plan.
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Yes No NA
Quality Improvement:
The anaesthetic department should have a quality improvement program in place.
Yes No NA
The program should include:
Regular monitoring of key performance indicators.
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Yes No NA
Analysis of data to identify areas for improvement.
Yes No NA
Implementation of corrective and preventive actions.
Yes No NA
he goal of the quality improvement program is to continuously improve the quality of anaesthesia care
and patient safety.
Yes No NA
2. Specific Requirements:
Anaesthesia Equipment:
All anaesthesia equipment should be properly maintained and calibrated.
Yes No NA
Regular safety checks should be conducted.
Yes No NA
Defective equipment should be removed from service immediately.
Yes No NA
Anaesthesia Drugs:
Anaesthesia drugs should be stored securely and dispensed only by authorized personnel.
Yes No NA
Expired drugs should be disposed of safely.
 Yes No NA
Accurate records of drug usage should be maintained.
Yes No NA
Infection Control:
The anaesthetic department should have a comprehensive infection control program.
Yes No NA
The program should include:
Auditor Name

Audit Date

Signature Of Auditor
Remarks (If Any)

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