AccrediSense
Back to Standards/Criterion 8.6.1
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorPartially 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.

8.6.1
Safety and performance improvement activities

Clinical Record Quality Audits and Quantitative Timeliness

Regular quantitative and qualitative clinical record audits monitor documentation completeness, diagnostic coding accuracy and discharge summary timeliness.

Compliance Criteria

  • 1Monthly quantitative medical record audit sampling 5% of discharged records
  • 2ICD-10 diagnostic coding and ICD-9-CM procedural coding accuracy audits
  • 3Discharge summary completion rate audit against the 48-hour compliance target
  • 4Quarterly medical record audit reports presented to the Medical Advisory Committee

Hospital Self-Rating

Rated by Pn. Mastura binti Ahmad on 22 Jan 2026

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

"Monthly medical record audits evaluate documentation quality and discharge summary timeliness against hospital targets."

AccrediSense Intelligence
thin

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

Unverified criteria:
  • Discharge summary completion rate audit against the 48-hour compliance target
  • Quarterly medical record audit reports presented to the Medical Advisory Committee
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)

Evidence Documents (1)

Audit reportAcceptedScore: 82/100

Monthly Medical Record Quantitative Quality & Timeliness Audit Dossier

40 pages · ENValid: 2025-01-01 to 2026-12-31

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 15 Apr 2026
Hospital: Fully met → Surveyor: Partially metDivergent
Committed Basis for Divergence:

"The hospital self-rated Fully Met on 22 January 2026, but the documentation audit register shows discharge summary timeliness fell below the 95% target in surgical wards throughout the evaluated audit period."

Monthly medical record audits are performed. However, audit results for Q4 2025 indicated that discharge summary completion within 48 hours in General Surgery achieved only 84.2% compliance against the 95% hospital benchmark.

Implement automated electronic notification alerts to surgical registrars for pending discharge summaries.

Strengthen monitoring and enforcement of the 48-hour discharge summary completion standard.