Back to Standards/Criterion 17A.3.2.20
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorPartially 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.3.2.20
Safety and performance improvement activities

Patient Progress Tracking Protocol 3.2

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

Compliance Criteria

  • 1Approved standard operating procedure for patient progress tracking reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day patient progress tracking 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 20 Jan 2026

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

"The department has established comprehensive operational policies for patient progress tracking. 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.

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

Review of patient progress tracking monitoring files in Physiotherapy Services identified overdue quarterly audits and incomplete corrective action verification.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for patient progress tracking.

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