Back to Standards/Criterion 09A.4.3.25
09A.4.3.25
Special requirements

Discharge Planning Protocol 4.3

The General Medical Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for discharge planning.

Compliance Criteria

  • 1Approved standard operating procedure for discharge planning reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day discharge planning 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 Dr. Azmi Razak on 25 Jan 2026

Evidence frozen on 30 March 2026 (14 days before survey)

"The department has established comprehensive operational policies for discharge planning. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."

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.

AR
Person-in-ChargeHead of Clinical Services & Consultant Physician
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)

Surveyor Rating

Committed 15 Apr 2026

Surveyor assessment revealed complete absence of structured monitoring logs and verified staff competency assessments for discharge planning in General Medical Services.

Formulate and approve a formal operational framework for discharge planning with designated staff competencies and active surveillance.

Develop mandatory SOP, assign operational indicator oversight, and conduct staff training within 60 days.