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Back to Standards/Criterion 09C.1.2.12
09C.1.2.12
Organisation and management

Antenatal Assessment Protocol 1.2

The Obstetric and Gynaecological Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for antenatal assessment.

Compliance Criteria

  • 1Approved standard operating procedure for antenatal assessment reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day antenatal assessment 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 12 Jan 2026

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

"The department has established comprehensive operational policies for antenatal assessment. 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 14 Apr 2026

Review of antenatal assessment monitoring files in Obstetric and Gynaecological Services identified overdue quarterly audits and incomplete corrective action verification.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for antenatal assessment.

Implement monthly documentation audits and review adherence rates during departmental quality meetings.