Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.
Post-operative Surveillance Protocol 2.4
The General Surgical Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for post-operative surveillance.
Compliance Criteria
- 1Approved standard operating procedure for post-operative surveillance reviewed within the last 3 years
- 2Designated qualified personnel assigned to monitor day-to-day post-operative surveillance 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 18 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The department has established comprehensive operational policies for post-operative surveillance. 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 post-operative surveillance reviewed within the last 3 years
- Designated qualified personnel assigned to monitor day-to-day post-operative surveillance 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.