Criteria-based clinical audit for NABH readiness
Clinical audit helps hospitals compare actual practice with defined criteria, identify gaps, complete RCA/CAPA and re-audit to confirm improvement.
Template Fields
- Topic
- Criteria
- Standard
- Sample
- Result
- Gap
- RCA/CAPA
- Owner
- Completion date
- Re-audit
How to Use This Tool
- Select a high-risk or high-volume topic.
- Define criteria and standard before collecting data.
- Audit a documented sample from real records or observations.
- Convert gaps into RCA/CAPA with owner and date.
- Re-audit to confirm whether practice improved.
NABH Implementation Relationship
Clinical audit supports PSQ and COP by converting patient-care evidence into measurable improvement actions and re-audit discipline.
Suggested Clinical Audit Topics
| Area | Suggested audit topics |
|---|---|
| OT | Surgical safety checklist, consent completeness, antibiotic timing, implant traceability |
| ICU | Ventilator bundle, central-line care, sedation review, handover completeness |
| Emergency | Triage documentation, time-to-doctor, CPR record completeness, referral handover |
| Nursing | Medication administration, fall-risk reassessment, pressure-injury prevention, patient education |
| Pharmacy | Prescription completeness, high-alert medication control, expiry checks, antibiotic review |
| Laboratory | Critical-value communication, sample rejection, TAT, quality-control documentation |
| Radiology | Patient identification, pregnancy screening where relevant, report turnaround, contrast-reaction readiness |
| Blood transfusion | Consent, cross-match documentation, transfusion monitoring, reaction reporting |
| Obstetrics | Partograph use, emergency response, newborn identification, consent and counselling |
| MRD | Record completeness, discharge summary turnaround, consent filing, coding/data quality |
Clinical-audit Template
CSV template for criteria-based clinical audit and re-audit tracking.
HTML Preview
| Topic | Criteria | Standard | Sample | Result | Gap | RCA/CAPA | Owner | Completion Date | Re-audit |
|---|---|---|---|---|---|---|---|---|---|
| Surgical safety checklist | Checklist completed before incision and before shifting | 95% compliance | 30 OT cases | Enter result here | Enter gap here | Enter RCA/CAPA here | OT Incharge | 2026-08-20 | 2026-09-20 |
| Medication administration | Two patient identifiers checked before administration | 100% compliance | 30 medication rounds | Enter result here | Enter gap here | Enter RCA/CAPA here | Nursing Superintendent | 2026-08-20 | 2026-09-20 |
Audit Action-plan Template
CSV template for RCA, CAPA, owner, evidence and re-audit follow-up.
HTML Preview
| Audit Topic | Gap | RCA | Corrective Action | Preventive Action | Owner | Target Date | Status | Evidence | Re-audit Date |
|---|---|---|---|---|---|---|---|---|---|
| Surgical safety checklist | Sign-out not documented in sampled records | Team handover step not reinforced | Brief OT team and assign sign-out responsibility | Add sign-out check to end-of-case nursing note | OT Incharge | 2026-08-20 | Open | Training record and re-audit sample | 2026-09-20 |
| Medication administration | Identifier check not consistently recorded | Staff use verbal confirmation only | Refresher training and observation audit | Monthly bedside medication-safety round | Nursing Superintendent | 2026-08-20 | Open | Training attendance and observation sheet | 2026-09-20 |
Related Resource Pages
Link to NABH Consultancy Services
These resources support implementation planning, but hospitals remain responsible for actual adoption, evidence and decisions. Humble Aim Enterprises provides independent readiness support and does not guarantee accreditation.
Official Sources
This clinical-audit page provides implementation support for hospital quality systems and does not reproduce NABH objective elements.
- NABH Hospital Accreditation Standards 6th Edition (opens in a new tab) - Official standards document. This site does not reproduce objective elements verbatim.
- NABH 6th Edition Implementation Notification (opens in a new tab) - Official implementation notification for effective-date context.
- NABH Hospitals Accreditation Programme (opens in a new tab) - Official hospital accreditation programme reference.
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