Surveyor Consensus & Allocation Dispute
Team leader to resolveLead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorFully met
Mr Ganesh PillaiRecorded 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.
8.3.1
Special requirementsElectronic Medical Record (EMR) Access and Audit Trail
Electronic medical record systems incorporate role-based access control, unique user logins, audit trails and automated session timeout controls.
Compliance Criteria
- 1Role-based access permissions restricting viewing and editing rights
- 2Unique user credentials with mandatory periodic password changes and 2FA
- 3Automated system audit logs recording every chart access, modification and export
- 4Automatic screen lock timeout after 5 minutes of terminal inactivity
Hospital Self-Rating
Rated by En. Azman bin Yahya on 18 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Role-based access permissions, unique user credentials and audit trail logging are enforced across electronic medical records."
thin
Evidence documents establish procedural intent but lack documented verification records for the current audit period.
Unverified criteria:
- Automated system audit logs recording every chart access, modification and export
- Automatic screen lock timeout after 5 minutes of terminal inactivity
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (1)
PolicyAcceptedScore: 95/100
Electronic Medical Record (EMR) Access Control & Audit Trail SOP
26 pages · ENValid: 2025-04-01 to 2028-04-01
AY
Person-in-ChargeManager, Information Technology & Digital Health
Head of DepartmentHead of Health Information & Medical Records
MA
Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)