Back to Standards/Criterion 17A.2.4.18
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorFully met
Mr Ganesh PillaiRecorded finding during tracer inspection

Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.

17A.2.4.18
Policies and procedures

Therapeutic Modalities Protocol 2.4

The Physiotherapy Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for therapeutic modalities.

Compliance Criteria

  • 1Approved standard operating procedure for therapeutic modalities reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day therapeutic modalities 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 En. Fauzi bin Ramli on 18 Jan 2026

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

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

AccrediSense Intelligence
unsupported

No evidence documents attached to substantiate this self-assessment claim.

Unverified criteria:
  • Approved standard operating procedure for therapeutic modalities reviewed within the last 3 years
  • Designated qualified personnel assigned to monitor day-to-day therapeutic modalities compliance
  • Regular documentation audits and evidence of corrective action implementation
  • Staff training records and competency assessments maintained in the department
Derived from AccrediSense Evidence Engine · 0 documents attached against 4 compliance criteriaGovernance disclosure (1.4.1.4)

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.

FR
Person-in-ChargeHead of Physiotherapy & Rehabilitation Services
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)

Surveyor Rating

Committed 14 Apr 2026

On-site audit of physiotherapy services operational records confirms that therapeutic modalities protocols are implemented with regular documentation and active staff adherence.

None specified.

None specified.