Checklist of Admissions Department for NABH accreditation preparation

Checklist of Admissions Department for NABH accreditation preparation

     A patients’ actual experience with hospital begins from the admission department. The department in addition to admitting a patient, also serves as a key point where all important information is shared between hospital and patient. The key performance expected from admissions department is time efficiency in admitting patient and achieving a positive first impression of the patient.

The admission department can help in addressing many NABH standards under AAC, PRE and ROM chapters. Here is the list of things that admission department staff must be prepared with for facing accreditation assessment.
1. Admission staff should be aware of hospital's policy of a patient's admission. S/he should know who has the authority to admit patients (i.e. list of doctors who can admit patients in the hospital)
2. A documented standard operating process (SOP) of admitting a patient should be available and followed. The SOPs should address all modes of admission, i.e.,
a. SOP for routine admission, through OPD
b. SOP for admission through emergency
c. SOP for admission through inter-hospital transfer
3. There should be a clear policy on what to do in case beds are not available and admission staff must be aware of it
4. There should be a clear policy on ‘how to admit an unidentified patient’ and admission staff must be aware of it
5. Each new patient upon registration is given a ‘Unique Identification Number’. The same UIN shall be used on all medical documents of the patient
6. Admission staff must be well aware of ‘scope of hospital services’ and ‘services that are not in the scope of the hospital
7. Admission staff must know all the rights of patient and family
8. A general consent should be taken from all patients getting admitted
9. Admitting staff must know the scope of general consent and must explain it to patient before getting his/her signature
10. A written estimate of cost must be given to patient at the time of admission. This can be given by admitting staff after coordinating with admitting doctor and accounts department and should be as per standard pricing of hospital services. Alternatively, hospital can assign this responsibility to any other department, such as accounts. In any case written estimate should be given before patient takes admission decision.
11. Admission staff should well understand ‘confidentiality of patients’ information’ and must know rules for protecting information
12. At the time of admission following information must be shared with patient and family
 a. Categories of rooms/beds available with rates and facilities. 
 b. Whether the category of bed will affect other treatment cost or not
 c. Additional chargeable services (such as ordering additional meals, use of internet etc.) that are applicable
d. Name of admitting doctor
 e. Visit schedule of doctor
 f. Hospital’s policy on patients’ belongings
g. Visitor timing and restrictions
h. Meal timings and whether outside meals are allowed
i. Rules and regulations of hospital applicable to patient and family, such as no smoking, no littering, restricted entry etc. (It is better that a printed document stating all such rules should be given to patient)
13. In case patient has a health insurance, necessary information for insurance processing must be provided either through admission department or by TPA desk
14. Following information must be shared with patient by the admitting doctor, before admission. (Admission department can coordinate to ensure that these information are provided)
a. Diagnosis or provisional diagnosis
b. Clinical reason for admission and plan of care (and indication if the plan of care is likely to change with further investigation)
c. Approximate cost of treatment (can be facilitated by admission or accounts department)
d. Expected duration of stay
e. Urgency or non-urgency of admission
15. All patients getting admitted must be educated on patients’ rights and responsibilities. This can be done through several ways such as display, or by handing over a patient rights booklet or by verbally explaining the rights to patients
16. Patient should be informed about complaint registration and redress mechanism of the hospital

Quality Indicators


1. Average time taken per admission


2. Average waiting time of patients for admission
3. % of admission for which general consent not taken
4. % of admission for which written estimate of cost not given
5. % of complaints that indicate lack of information required to be given at the time of admission

Send a message