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Back to Standards/Criterion 09C.1.4.14
09C.1.4.14New in the 7th Edition
Policies and procedures

Postnatal Monitoring Protocol 1.4

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

Compliance Criteria

  • 1Approved standard operating procedure for postnatal monitoring reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day postnatal monitoring 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 14 Jan 2026

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

"The department has established comprehensive operational policies for postnatal monitoring. 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

Audit of Obstetric and Gynaecological Services logs revealed intermittent documentation for postnatal monitoring, with sampled shift handover records missing mandatory supervisory sign-offs.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for postnatal monitoring.

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