AccrediSense
Back to Standards/Criterion 8.2.1
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.

8.2.1Core Standard
Policies and procedures

Medical Record Content and Clinical Entry Quality

Medical records contain complete patient identification, clinical notes, treatment plans, signed surgical consent forms, diagnostic reports and discharge summaries.

Compliance Criteria

  • 1All clinical entries dated, timed and signed with doctor name and MMC registration number
  • 2Standardized medical record forms and structured progress note format
  • 3Discharge summary completed within 48 hours of inpatient discharge
  • 4Operation notes and anaesthetic charts completed immediately post-procedure

Hospital Self-Rating

Rated by Pn. Mastura binti Ahmad on 16 Jan 2026

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

"Clinical entry guidelines require timed and signed documentation. Operation notes and discharge summaries are tracked for completeness."

AccrediSense Intelligence
thin

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

Unverified criteria:
  • Discharge summary completed within 48 hours of inpatient discharge
  • Operation notes and anaesthetic charts completed immediately post-procedure
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)

Evidence Documents (1)

PolicyAcceptedScore: 93/100

Clinical Documentation Standards & Medical Record Timeliness Policy

30 pages · ENValid: 2025-01-01 to 2028-01-01

Linked Performance Indicators (1)

PI-08-001Medical Records

Inpatient Discharge Summary Completion Rate Within 48 Hours

18 readings recorded (Target: >= 95%)
MA
Person-in-ChargeHead of Health Information & Medical Records
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)

Surveyor Rating

Committed 14 Apr 2026

Sampled inpatient medical records demonstrated good clinical note quality, clear diagnostic entries and prompt operative note documentation.

Encourage doctors to print their names alongside signatures on physical documentation.

Sustain clinical documentation quality standards.