AccrediSense
Back to Standards/Criterion 8.1.1
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.

8.1.1Core Standard
Organisation and management

Medical Record Management and Security

The Medical Records Department maintains secure, standardized, complete and accessible patient medical records with physical and digital confidentiality controls.

Compliance Criteria

  • 1Secure medical record file room with fire suppression and controlled badge access
  • 2Unique Medical Record Number (MRN) assigned to each patient across all visits
  • 3Policy on medical record tracking, retrieval tracking and movement logs
  • 4Retention and disposal schedule in accordance with national statutory guidelines

Hospital Self-Rating

Rated by Pn. Mastura binti Ahmad on 14 Jan 2026

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

"The medical record file room maintains strict physical security and computerized record tracking with barcode file management."

AccrediSense Intelligence
thin

Evidence documents establish procedural intent but lack documented verification records for the current audit period.

Unverified criteria:
  • Policy on medical record tracking, retrieval tracking and movement logs
  • Retention and disposal schedule in accordance with national statutory guidelines
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)

Evidence Documents (1)

PolicyStaleScore: 60/100

Medical Records Archival & Physical Security SOP (2023 Edition)

Retention schedules require updating to reflect digital scanning retention amendments.

18 pages · EN, MSValid: 2023-02-01 to 2024-09-30
MA
Person-in-ChargeHead of Health Information & Medical Records
Head of DepartmentQuality Manager
RI
Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)

Surveyor Rating

Committed 14 Apr 2026

Medical Records file room is secure with controlled access, FM200 fire suppression and efficient barcode record tracking.

Accelerate digitization of legacy physical patient charts.

Maintain secure physical and electronic record management.