7.1.1Core Standard
Organisation and managementPatient Charter and Informed Consent
Patient rights, responsibilities and informed consent procedures are respected, documented and communicated in languages understood by the patient population.
Compliance Criteria
- 1Patient Charter displayed prominently in Bahasa Malaysia, English, Mandarin and Tamil
- 2General admission and specific procedural informed consent policies and forms
- 3Verification of patient understanding prior to elective surgical / invasive procedures
- 4Provision for official language interpreter services for non-fluent patients
Hospital Self-Rating
Rated by Pn. Rohani binti Ismail on 15 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Patient charter and bilingual informed consent procedures are implemented. Informed consent is verified before all surgical interventions."
thin
Evidence documents establish procedural intent but lack documented verification records for the current audit period.
Unverified criteria:
- Verification of patient understanding prior to elective surgical / invasive procedures
- Provision for official language interpreter services for non-fluent patients
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (1)
PolicyAcceptedScore: 92/100
Patient Rights & Informed Consent Governance Policy
24 pages · EN, MSValid: 2024-08-01 to 2027-08-01
Linked Performance Indicators (1)
PI-07-001Patient Rights & Ethics
Elective Surgical Informed Consent Documentation Audit Compliance
18 readings recorded (Target: >= 95%)
RI
Person-in-ChargeQuality Manager
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)