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NABH assessors review whether every dialysis session has a complete, signed record — pre/post vitals, machine settings, ultrafiltration, complications, and medications. This guide covers what session documentation must capture and how to make completeness routine.
Each dialysis session produces a chart: pre-dialysis assessment and vitals, machine settings (blood flow, dialysate, UF goal), intra-session monitoring, post-dialysis vitals and weight, medications given (heparin, ESA), and any complications with their management.
NABH review focuses on completeness — whether every session has all of these, documented by the responsible nurse and signed. Missing machine settings or vitals is the classic non-conformance.
The record must identify who delivered the care and who signed the chart — accountability is part of the documentation standard. Structured charting that requires the key fields before sign-off prevents silent gaps.
The completeness rule applies to every session, not just sampled ones — the record is the evidence that care was documented as delivered.
Chair-side charting software that validates the session record before sign-off (missing machine settings, vitals, or complication notes block completion) makes completeness the default instead of a hope.
Regular internal audits of a sample of session charts catch drift before an accreditation review does — review completeness monthly and address patterns.
Standards and rules change — verify current requirements with the authorities listed above.