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NABH Entry-Level self-assessment, 2nd Edition.

Up to 62 questions across NABH’s ten chapters plus eligibility, filtered to the services your hospital actually runs. You get a chapter-wise gap list, the written procedures you still need, and NABH’s fee for your bed count. Your answers stay in your browser.

1 · Your hospital

Services you provide (questions for services you don’t have are hidden):

2 · Questions (49)

Eligibility & licences

  1. Is the hospital an allopathic facility (not a standalone dental, diagnostic or physiotherapy centre)? (Eligibility)

  2. Has the hospital been functioning for at least six months? (Eligibility)

  3. Have you been following the standards for at least three months? (Eligibility)

  4. Was bed occupancy at least 20% over the last three months? (Eligibility)

  5. Are all registrations your services need current, for example Clinical Establishments registration, fire NOC, biomedical waste authorisation, and PC-PNDT, MTP, AERB or drug licences where they apply? (ROM.1b)

Access, assessment & continuity of care

  1. Are the services you provide defined in writing and displayed where patients can see them, in English and the local language? (AAC.1a–b)

  2. Is there a written procedure for registering and admitting OPD, day-care, indoor and emergency patients? (AAC.2a)

  3. Does every patient get a unique ID at registration that is used on all their records? (AAC.2b)

  4. Is there a written process for transferring patients in and out, or referring them? (AAC.2c)

  5. Is the initial assessment of every patient done in a standard, documented format? (AAC.3a)

  6. Is a named, qualified doctor responsible for each patient, with reassessment at defined intervals? (AAC.4a–b)

  7. Does every patient get a signed discharge summary with the required contents and follow-up advice in plain words? (AAC.7a–c)

Care of patients

  1. Is care provided in line with applicable laws and regulations for each of your services? (COP.1a)

  2. Do you identify and protect vulnerable patients (elderly, children, disabled, unconscious)? (COP.9a)

  3. Is pain assessed and managed, and every admitted patient screened for nutritional risk? (COP.10a, 10c)

Management of medication

  1. Is there a written medication-management policy and a hospital formulary that is reviewed? (MOM.1a–b)

  2. Are medicines stored safely, with high-risk and look-alike / sound-alike medicines stored as per written guidance? (MOM.2a–b)

  3. Are prescriptions written only by authorised doctors, legibly, dated, timed and signed, meeting your minimum prescription requirements? (MOM.3a–b)

  4. Is there a list of high-risk medicines, and are dispensed medicines labelled? (MOM.4a–b)

  5. Are medicines given only by permitted staff, after checking patient, dose, route and time, with every dose documented? (MOM.5a–b, 5e)

  6. Are near misses, medication errors and adverse drug events recorded, reported and analysed within a set time? (MOM.5g)

  7. If you use narcotic or psychotropic drugs, are they stored securely and every use and disposal recorded? (MOM.6a–b, 6d)

Patient rights & education

  1. Are patient and family rights and responsibilities displayed and explained? (PRE.1a)

  2. Are privacy during examination and confidentiality of patient information protected? (PRE.1c, 1e)

  3. Are patients told the expected cost of treatment, and can they get their clinical records? (PRE.1i–j)

  4. Is informed consent taken after explaining risks, benefits and alternatives, as the law requires? (PRE.2a–c)

  5. Is there a way to capture patient feedback and resolve complaints? (PRE.2f)

Infection prevention & control

  1. Is there a documented infection-control programme, and are hand hygiene and standard precautions followed? (IPC.1a–b)

  2. Are safe injection and infusion practices followed? (IPC.1c)

  3. Is pre- and post-exposure prophylaxis (e.g. needle-stick) available to staff? (IPC.1e)

  4. Is biomedical waste segregated, stored and handed over as per the rules? (IPC.2a)

  5. Are cleaning and disinfection practices defined and monitored? (IPC.2c)

Patient safety & quality

  1. Is there a quality and patient-safety programme with a named person in charge? (PSQ.1a, 1d)

  2. Do you track key indicators for infection control and patient safety? (PSQ.2a–b)

Responsibilities of management

  1. Is the hospital's mission displayed, and is there a framework for ethical conduct? (ROM.2a–b)

  2. Do committees oversee infection control, quality and patient safety, and do they actually meet? (ROM.3a)

Facility management & safety

  1. Are facility safety inspection rounds done at least once a month? (FMS.1a–b)

  2. Is there a written maintenance plan (preventive and breakdown) for equipment and utilities? (FMS.2a)

  3. Are drinking water and electricity available round the clock? (FMS.3a)

  4. Is there a written plan for fire and non-fire emergencies, with drills? (FMS.4a)

Human resources

  1. Is there a code of conduct for staff? (HRM.1c)

  2. Does every new staff member get induction training, with regular job-specific training after that? (HRM.2b–c)

  3. Is there a defined process for staff discipline and grievances? (HRM.3b)

  4. Are staff health and occupational hazards looked after as per a policy? (HRM.4a)

  5. Is there a personal file for every staff member, with credentials (degrees, registrations) verified? (HRM.5a–b)

Information & records

  1. Have you identified the information patients, staff and authorities need, and how it is shared? (IMS.1a)

  2. Does every medical record carry the patient's unique ID and give a complete, chronological account of care? (IMS.2a–b)

  3. Are medical records reviewed periodically? (IMS.2d)

  4. Is patient information (paper and electronic) kept confidential and secure, and disclosed only as authorised or required by law? (IMS.3a–b)

How to use this well

Answer honestly, “Partly” usually means you do it but haven’t written it down, and assessors look for evidence, not intent. Then read the matching objective elements in NABH’s Entry-Level Guidebook (2nd Edition), each question shows its code, and check the current rules on NABH’s programme page. Fees are from NABH’s fee notification.

The questions cover the main elements rather than all 189, and we don’t label each one Core or Commitment, use the Guidebook for that. For the process, timelines and what it costs overall, read NABH for small hospitals. Last reviewed 29 September 2026.

Common questions

What changed in NABH Entry-Level 2nd Edition?

From 1 January 2026 NABH merged its separate entry-level standards for small healthcare organisations and hospitals into one standard: 10 chapters, 46 standards and 189 objective elements, graded Core, Commitment and Excellence. Facilities of 1–50 beds are assessed on Core elements only in the first cycle; 51 beds and above on Core and Commitment.

Who is eligible for NABH Entry-Level certification?

Allopathic hospitals that have been functioning for at least six months, have implemented the standards for at least three months, and had at least 20% bed occupancy over the last three months. From 1 October 2026, hospitals above 300 beds move to full accreditation instead (with exceptions for new and government hospitals).

What is the NABH Entry-Level fee?

From 1 October 2026, for a two-year cycle paid upfront, plus GST: ₹21,000 (up to 5 beds), ₹40,000 (6–20 beds), ₹80,000 (21–50 beds), ₹1,60,000 (51–100 beds), ₹2,00,000 (101–300 beds).

Which documents does NABH Entry-Level require?

The Guidebook marks certain objective elements as needing written documentation, for example registration and admission, transfer and referral, specimen handling, imaging critical results, medico-legal and emergency care, triage, vulnerable patients, pain and nutrition screening, storage of high-risk medicines, labelling, narcotics, patient feedback and complaints, safe injection practice, and fire and non-fire emergencies. The self-assessment lists the ones you still need.

Is this an official NABH tool?

No. NABH's own self-assessment tool, E-Mitra, is available after registering on the NABH portal. This is an independent, no-login checklist written in our own words from NABH's published Guidebook; it does not certify anything and MedStream is not affiliated with NABH.

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