Surveyor Consensus & Allocation Dispute
Team leader to resolveLead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorFully met
Pn Zaiton AbdullahRecorded finding during tracer inspectionAwaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.
5.1.3Core Standard
Policies and proceduresNursing Care Assessment and Care Planning
Patients receive comprehensive nursing assessment upon admission and individualized nursing care plans tailored to identified clinical needs.
Compliance Criteria
- 1Documented nursing initial assessment completed within 2 hours of inpatient admission
- 2Individualized nursing care plan incorporating fall, pressure ulcer and pain scores
- 3Regular evaluation and updating of nursing care goals during clinical handovers
- 4Nursing discharge planning initiated upon patient admission
Hospital Self-Rating
Rated by Matron Norliah binti Hashim on 13 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Admission nursing assessments and individualized care plans are initiated within 2 hours of inpatient arrival with fall and pressure injury scoring."
thin
Evidence documents establish procedural intent but lack documented verification records for the current audit period.
Unverified criteria:
- Regular evaluation and updating of nursing care goals during clinical handovers
- Nursing discharge planning initiated upon patient admission
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (1)
Audit reportAcceptedScore: 91/100
Inpatient Nursing Initial Assessment & Care Plan Sample Audits
26 pages · ENValid: 2025-09-01 to 2026-09-01
NH
Person-in-ChargeDirector of Nursing
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Pn. Zaiton Abdullah (Nursing & Quality Surveyor)