NABH Documentation: How Hospital Software Helps

NABH in brief

The National Accreditation Board for Hospitals & Healthcare Providers (NABH) accredits hospitals in India against published standards. The current hospital standards are the 6th edition, effective from 1 January 2025, available from the NABH hospital accreditation page.

The standards are organised in ten chapters. The first five are patient-centred and the last five are organisation-centred. Each chapter has standards, and each standard has objective elements that assessors check, many of them through records. Abbreviations such as AAC, COP and IMS are explained in our glossary.

The ten chapters and where software helps

Medical records under the IMS chapter

The Information Management System chapter is where software matters most. Its intent is that the right information is available to the right person at the right time, that confidentiality, integrity and security of records are maintained, and that every patient has a complete and accurate medical record. Several objective elements map directly to software features:

• A unique identifier is assigned to the medical record. The HMS gives each patient one ID across OPD, IPD, lab and pharmacy.
• The record is complete, up to date and chronological. One timeline per patient, rather than separate registers per department.
• Only authorised staff make entries, and the author can be identified. Individual logins with role-based access, never a shared login.
• Each entry is signed, dated and timed. The system records the user and time automatically, and corrections leave an audit trail instead of overwriting.
• The record shows continuity of care: reasons for admission, diagnosis, care plan, assessments, investigation results, procedures, transfer details and a signed copy of the discharge summary.
• Care providers can access current and past records. Doctors see previous visits and reports during the consultation.
• Confidentiality, integrity and security are maintained, and information is disclosed only as authorised by the patient or as required by law.
• Records are retained according to the hospital's requirements, and destroyed only in line with written guidance.
• Medical records are reviewed periodically using a representative sample, with deficiencies documented and corrected.

The standards also expect a contingency plan that keeps information capture going when systems are unavailable. Our guide to cloud vs on-premise hospital software includes a simple downtime plan.

Discharge summaries and consent

Under the AAC chapter, the hospital defines the content of the discharge summary, gives one to every patient at discharge, and keeps its content standard, including follow-up advice, medication and instructions on when and how to obtain urgent care. A discharge summary template in the HMS, filled from the admission record, makes the content consistent across doctors and prevents missing sections. Our discharge summary format guide has a field table and a template you can adapt.

Informed consent appears in several chapters, for procedures, anaesthesia, sedation and transfusion among others. NABH also lists the percentage of medical records with incomplete or improper consent as a quality indicator. Keeping consent records attached to the admission or procedure in the software makes both the consent and the indicator easier to check.

Quality indicators the software can calculate

The 6th edition includes a list of key performance indicators to monitor, with definitions. For several of them NABH notes that the data can be captured either through the HIS or through an audit. When your software records the right time stamps, these indicators come from every patient rather than a sample.

A live OPD queue that time-stamps each token and each consultation already holds most of what the OPD waiting-time indicator needs. To estimate waits for a session, try our OPD wait-time calculator; for inpatient planning, the bed occupancy calculator works out occupancy and average length of stay.

Audit trail, access control and privacy

Assessors look at who made an entry and when, and whether records are protected. The same controls are needed under the Digital Personal Data Protection Act, 2023, which makes the hospital responsible for reasonable security safeguards over personal data, including data processed by its software vendor. Our guide to the DPDP Act for hospitals and clinics lists the steps.

• Separate login for every staff member, removed on the day they leave.
• Access by role, so a receptionist does not see what only a doctor should.
• Corrections and cancellations recorded with the user, time and reason.
• Clinical documents opened only through private links, never public ones.
• Regular backups and a tested restore.

Preparing for assessment: a practical sequence

1. Read the current standards and list the objective elements that depend on records.
2. Agree standard templates for initial assessment, care plan, consent, operation notes and discharge summary, and set them up in the software.
3. Give every staff member their own login and the right role.
4. Start capturing the time stamps that the indicators need, and review the figures monthly.
5. Run a monthly medical record review on a sample of active and discharged patients, and record corrective actions.
6. Write down your retention, disclosure and downtime procedures, and train staff on them.

Common mistakes

• Buying software expecting it to "make us NABH ready" without changing processes.
• Keeping consent forms only on paper, so the record and the indicator never match.
• Sharing logins, which makes entries impossible to attribute.
• Calculating indicators by hand at month-end from incomplete registers.
• Letting each doctor write discharge summaries in a different format.

How Sehat Nxt helps

Sehat Nxt keeps one record per patient across the live OPD queue, EMR and digital prescriptions and IPD management. In IPD, records are signed, amended or voided with an audit trail, and the case file prints on your letterhead in date order. Access follows each staff member's role through staff management, and the laboratory keeps orders and reports with the same patient.

Accreditation still depends on your processes, and your quality team still owns the indicators, the reviews and the corrective actions. Well-kept records make that work easier. Plans start from ₹999 per month. Book a free demo and bring a sample of your current discharge summary and consent forms.