NABH expects a controlled set of documents, from policies and SOPs down to work instructions, forms and records, with every objective element marked by an asterisk backed by written documentation. Each document is named, dated for issue and review, and signed by the people who wrote and approved it.
The documentation pyramid
The 6th Edition sets out five layers. Mission and vision at the top, then policies and procedures, work instructions, forms, formats and records, and documents of external origin such as licences and statutory clearances.1 Records are filled forms, and while forms can be changed through a controlled process, records cannot be altered.1
| Layer | What it is | Example |
|---|---|---|
| Policies | Principles that guide how activities are run | Patient rights and responsibilities |
| SOPs | The steps to complete a task, by department | Registration and admission |
| Work instructions | Detailed physical steps for one task | Hand hygiene at the bedside |
| Forms and records | Formats, and the filled records of what was done | Consent form, signed |
| External documents | Licences, statutory clearances, contracts | State registration certificate |
What makes a document controlled
Every controlled document has a name, a purpose, dates of creation, approval and review, named signatories for creation, approval and alteration, and numbered pages, usually in a control box at the top.1 Most organisations review their SOPs at least once a year, and obsolete copies are removed from every place of use.1 NABH's application asks for the self-assessment toolkit and supporting documents that address the documentation the standard requires.2
- List every asterisked element. Each objective element marked with an asterisk needs system documentation.
- Map documents to elements. One register of documents, each linked to the elements it answers.
- Write with the people who do the work. In their language, in the order the task is done.
- Add the control box. Name, code, issue date, review date and signatories on each document.
- Put documents where they are used. Available day and night, with obsolete copies removed.
- Review on a cycle. At least once a year, and whenever a process or a law changes.
- Name of organisation ______ Document code ______
- Department or process ______ Version ______
- Date of issue ______ Date of next review ______
- Prepared by, designation ______ Approved by, designation ______
- Objective elements answered ______
Questions
Which objective elements need written documentation?
Those marked with an asterisk in the standards, which NABH calls mandatory system documentation.
Can poor documentation lower our score?
Yes, the scoring is based on implementation, but inadequate or inappropriate documentation can lower a score by one.
Do records have to be on paper?
No, the 6th Edition says forms, formats and records can be physical or electronic.
Sources
- 1NABH, 2025NABH Accreditation Standards for Hospitals, 6th Edition, effective 1 January 2025Read source
- 2NABH, 2025Policies and Procedures for Assessment, Surveillance and Re-assessment of HCO, Issue 5Read source
Written by the wai team from National Accreditation Board for Hospitals and Healthcare Providers guidance, checked on 16 October 2026. This is guidance, not legal advice. NABH does not endorse wai or any software.