Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.
Clinical Documentation Protocol 3.4
The Nursing Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for clinical documentation.
Compliance Criteria
- 1Approved standard operating procedure for clinical documentation reviewed within the last 3 years
- 2Designated qualified personnel assigned to monitor day-to-day clinical documentation compliance
- 3Regular documentation audits and evidence of corrective action implementation
- 4Staff training records and competency assessments maintained in the department
Hospital Self-Rating
Rated by Matron Norliah binti Hashim on 22 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The department has established comprehensive operational policies for clinical documentation. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."
No evidence documents attached to substantiate this self-assessment claim.
- Approved standard operating procedure for clinical documentation reviewed within the last 3 years
- Designated qualified personnel assigned to monitor day-to-day clinical documentation compliance
- Regular documentation audits and evidence of corrective action implementation
- Staff training records and competency assessments maintained in the department
Evidence Documents (0)
A criterion with no document reads as unevidenced to the survey team.
Attach relevant hospital policies, registers, audit reports, or training records.