N.A.B.H.

PARAMETER SHEET
Network Hospital Grading Proforma Ver: G\N -1.0
General Information 24Hrs. Indoor YES \ NO
Name of Healthcare Unit
Registration Number (If Registered)
Registering Authority
Owner / CMD’s Name & Qualification

Address

Landmark, if any (Location)

City /Taluk
District
State
Pin
Telephone(s) with STD Codes
Fax Number(s)
Mobile Phone/s
E-mail Id
Website
Other Details:
Whether your Organization is a Non Profit Organization? YES \ NO
Are you registered with Income Tax Dept. for IT Exemption? YES \ NO
PAN No.
Bank Details:
Name of Bank
Branch & Address
Account Number
Account in the Name of
IFSC Code:
Hospital Details:
Type of Ownership Proprietary Charitable Trust Private Limited Public Limited

Leased Partnership Corporate

Total Land Area , Super Built up Area (Area in Sq. Feet)

Hospital Type: Multi Specialty Single Specialty Clinic Other (specify
(Please tick the appropriate box)
If single specialty please mention the specialty: Number of Total Beds in the Hospital:

Contact Details:
Contact Person for Name Tel. No. Ext. Mobile No.
Head of Operation/ admin
Accounts and Billing
Admission
Clinical Information
Interaction with Star
Medical Records
ICU
Casualty
Operation Theater/Labour Room

1 Date:
Form Confidential Signature & Seal
 N.A.B.H. PARAMETER SHEET
OT – COMPLEX:

Number of OT: Major Minor

EQUIPMENT DESCRIPTION WITH

DATE OF MANUFACTURE
Laminar Air Flow (Yes \ No)

Hepa Filter (Yes \ No) Vinyl Floor

Type of OT Table/Ortho attachment

Light LED / Halogen / Tube-light

Multiparameter Monitor With Capnography

C-Arm – Specification

Laparoscopy Unit ( Brand & Specification)

Boyle’s Apparatus / Defibrillator

Operating Microscopy / Diathermy

Radiant Warmer

Autoclave

Others

2 Date:
Form Confidential Signature & Seal
 N.A.B.H. PARAMETER SHEET
ICU \ IMCU :

Man power: Doctors Staff Nurse Assistant Supporting Staff

EQUIPMENT DESCRIPTION WITH DATE OF

MANUFACTURE
Central Oxygen / Suction

Number of Ventilators with details

Monitor

Pulse oxymeter

Others

Details of Beds

Type of Bed No. of Beds No. of Toilets Staff

General Ward – Male

General Ward – Female

A.C./Deluxe/Suite

Single Bed
Sharing

ICU \ IMCU

Post Operative Ward

Day Care

Dialysis

Burns Unit

3 Date:
Form Confidential Signature & Seal
Diagnostic Services
Lab Services Yes No Description
Hematology

Biochemistry

Microbiology

Serology

Histopathology

Biomedical Department

RADIOLOGY Yes No Description

Digital X-Ray

Contrast Studies

Portable X-ray

IMAGING Yes No Description

Ultra Sound

Mammogram

Color Doppler / Duplex

Scan
CT- Scan

MRI

PET Scan

4 Date:
Form Confidential Signature & Seal
S.NO PARTICULAR AVAILABILITY

1 Pharmacy

2 Blood bank

3 TSSU/CSSD

4 Piped medical gas system/ Gas Manifold

5 Security

6 House keeping

7 Ultrasonography

8 cardiology Diagnostic services (TMT,ECHO,ECG)

9 Kitchen

10 Ambulance

11 Laboratory

12 Radiology services

Multi specialty Hospital - please indicate the specialties available in your hospital: (Please tick the appropriate box)

Anesthesia Oncology General Surgery Neonatology

GeneralMedicine Endocrinology Cardio Thoracic Surgery Pediatrics
Cardiology Hepatology Orthopedics Dental
Pulmonology Rheumatology Surgical Gastro Others (Specify)
Urology ENT Neuro Surgery 
Nephrology Ophthalmology Plastic Surgery 
Neurology Dermatology Transplant Surgery 
Psychiatry Gastroenterology Obstetrics & Gynecology

S.NO PARTICULAR DETAILS

1 Number of building
2 Number of floor
3 Number of lift
4 Number of ramps
5 Number of staircase

Form Confidential Signature & Seal

Please indicate the equipments available in your hospital:

Cardiology Yes No Description

ECG

ECHO
TMT

Holter Monitor
Cath Lab
Nuclear Scan

ENT Yes No Description

Audiometer
Triple Endoscopy

Gastroenterology Yes No Description

OGD

Colonoscopy
ERCP

Gynecology Yes No Description

Labour Room

Fetal Incubator
Neonatal resuscitation kit

Fetal Monitor
Neonatal ICU

Opthalmology Yes No Description

Phaco

Laser

Others Yes No Description

PFT
EEG
EMG
Others

Medical Records (Tick which ever is applicable)

Number & Year of
1 Identification of indoor patient By Name Admission Unique Identifier

2 Medical Records Maintained for <1 Year 1 to 3 Years > 3 Years

3 Medical Records Management Person Section Department

Form Confidential Signature & Seal

 OTHER AMENITIES / Credits Available
S. No. Amenities Details
JCI (USA)/ ACHSI(Australia)/ TRENT (UK/Europe)/CCHSA(Canada) -
1
Accreditation
2 NABH
3 NABL
4 Recognition for DNB
5 CSSD
6 ICD Coding / MRD
7 Medical Audit
8 Blood Bank
9 Fire Safety Mechanism
10 Ambulance
11 In house 24 Hrs Pharmacy
12 Computerized Billing with CGHS Available Billing
13 IT Solutions (Software License)
14 Backup Generator
15 Pantry
16 Others

S.NO DISPLAY AVAILABILITY

1 Fire emergency exits
2 Emergency exit plan
3 Lift liscence
4 Drug liscence
6 Hand wash display
7 Bio hazard symbol
8 Radiation areas symbol
9 BMW (color codeing)
10 No smoking
11 Mission statement
12 Floor plan
13 Floor plan (Floor wise)
14 Directional signages
16 Scope of services
17 Timing for OPD consultation
18 Patient rights & responsibility
19 CPR Process
20 How to use fire extingusher
21 Caution signages
22 Material saftey data sheet
24 Emergency Phone Numbers
25 Notice board
6 Date:

Form Confidential Signature & Seal