Roles and responsibilities of a staff nurse in an NABH-accredited hospital

1.Accurate Documentation

• Record all nursing care provided to the patient in real time.

• Ensure entries are legible, dated, timed, and signed with designation.

• Document vital signs, nursing assessments, interventions, medication administration, and patient responses.

• Maintain daily nursing notes as per hospital policy.

---

2. Following Hospital Policies and NABH Standards

• Adhere to hospital documentation policies and formats (e.g. intake output chart, TPR chart, nursing assessment, progress notes).

• Ensure completeness of records before patient transfer or discharge.

---

3. Medication Documentation

• Record medication administration correctly in the medication chart (dose, time, route, signature).

• Report and document any medication errors or adverse reactions as per policy.

---

4. Consent Verification

• Ensure that necessary consents (e.g. for surgery, blood transfusion) are signed and filed properly before procedures.

---

5. Handover Responsibility

• During shift change, provide complete and documented handover to the next nurse, ensuring continuity of care and updated records.

---

6. Patient Identification and Safety

• Document patient identification checks before any procedure or medication administration.

• Report and record any incidents, falls, or patient complaints immediately in the IPD file and incident reporting system.

---

7. Discharge Documentation

• Assist in discharge process, ensuring nursing notes are completed up to discharge time.

• Document patient education and discharge instructions given, including follow-up advice.

---

8. Infection Control Documentation

• Record infection control practices (e.g. device care, catheter care, wound dressing) as per NABH infection control standards.

---

9. Confidentiality and Record Management

• Maintain confidentiality of patient information.

• Ensure IPD files are kept in designated areas securely when not in use.

---

10. Audit Preparedness

• Keep nursing documentation audit-ready by ensuring completeness and compliance with NABH standards for medical records.

Prepared By 

Mr. Naveen Kumar Prajapati

Medical Record Officer

Fatima Hospital Padri Bazar Gorakhpur