A detailed, chapter-by-chapter gap assessment for Small Healthcare Organisations to identify what is missing before NABH accreditation
Assessment Progress
0 of 122 items assessed
NABH SHCO Chapters
AAC - Access, Assessment and Continuity of Care
Admission, assessment, care planning and discharge processes that ensure every patient receives timely and coordinated care.
Compliance so far0% · Gap 100%
Is there a documented admission policy with clearly defined admission criteria?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Are admission and registration procedures defined, documented and followed for all patients?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Is a process in place to register and attend to patients in medical emergencies without delay?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Is an initial clinical assessment of every patient documented on arrival?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Are timeframes defined within which initial assessment must be completed?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Is a system in place for patients who may require observation or transfer to a higher facility?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Are comprehensive nursing and medical assessments completed and documented for in-patients?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Is patient reassessment done at defined intervals and recorded?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Is a documented care plan developed based on the assessment of each patient?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Are care plans reviewed and updated in response to changes in patient condition?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Is a defined referral and transfer policy in place for patients requiring specialist or higher-level care?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Are referral and transfer procedures documented, including transfer of medical records?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Is a structured discharge policy defined for all patients?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Are discharge summaries prepared and given to patients, including medication and follow-up instructions?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
Is a continuity of care and follow-up mechanism in place after discharge?
Compliant - no gap · Partially Compliant - minor gap · Non-Compliant - major gap
About NABH SHCO
The NABH Small Healthcare Organisations (SHCO) accreditation programme is designed for smaller facilities including clinics, nursing homes, day care and diagnostic centres. It assesses quality and operational systems across 10 chapters.
AAC - Access, Assessment and Continuity of Care
COP - Care of Patients
MOM - Management of Medication
PRE - Patient Rights and Responsibilities
IPC - Infection Prevention and Control
PSQ - Patient Safety and Quality
ROM - Responsibility of Management
FMS - Facility Management and Safety
HRM - Human Resource Management
IMS - Information Management System
Gap Classification Guide
Compliant - no significant gap
Partially Compliant - minor gap, partially implemented
