Evidence Library
Accreditation evidence repository, AccrediSense Intelligence auto-match verification, and document freshness surveillance under the 30 March 2026 freeze.
Documents
38
Total registered in library
Accepted
33
Current & substantiated
Needing attention
5
Stale or low quality score
Criteria with no evidence
474
Unlinked in scope
AccrediSense Intelligence Auto-Match Recommendations
3 pendingNatural language cross-referencing between document content and criterion compliance clauses.
Strict verification protocol: Nothing is filed against a criterion without the hospital's confirmation.
- IT Disaster Recovery & Business Continuity Framework1.1.3.10(Information Technology Continuity and Cyber Resilience)
IT systems continuity is explicitly in scope of 1.1.3.10
74% match confidence·Doc ID: doc-06 - Chemical Safety Data Sheets (SDS) & Clinical Waste Consignment Manifests2.1.4(Hazardous Materials and Waste Management)
Chemical inventory aligns with hazardous material management requirement
68% match confidence·Doc ID: doc-12 - Hospital Outbreak Management Plan & Communicable Disease Protocols6.2.5(Outbreak Preparedness and Management Plan)
Outbreak protocol correlates with communicable disease notification standards
61% match confidence·Doc ID: doc-31
Filter Evidence Library
| Document Name | Type & Pages | Languages | Linked Criteria | Validity & Status | Quality Score |
|---|---|---|---|---|---|
Hospital Strategic Plan & Core Values Charter (2024–2028) doc-01·Uploaded by hs-rohani | Policy 36 pages | enms | Current Exp: 31 Dec 2028 | 94 / 100 | |
Board of Directors Strategic Governance Review Minutes doc-02·Uploaded by hs-rohani | Minutes 14 pages | en | Current Exp: 15 Jan 2027 | 92 / 100 | |
Hospital Clinical Governance Committee Terms of Reference & Master Hierarchy doc-03·Uploaded by hs-rohani | Policy 28 pages | en | Current Exp: 1 Dec 2027 | 88 / 100 | |
Private Healthcare Facilities and Services Act 1998 (Act 586) Operating Licence doc-04·Uploaded by hs-rohani | Licence 4 pages | msen | Stale (>12mo)Expired Exp: 30 Sept 2024 | 65 / 100 | |
Bomba Fire Safety Certificate (Sijil Perakuan Bomba) doc-05·Uploaded by hs-zaki | Certificate 2 pages | ms | Current Exp: 31 May 2026 | 96 / 100 | |
IT Disaster Recovery & Business Continuity Framework doc-06·Uploaded by hs-azman | Policy 42 pages | en | Unlinked | Current Exp: 1 Jun 2027 | 78 / 100 |
Workforce Staffing Establishment & Nurse-to-Patient Ratio Audit doc-07·Uploaded by hs-aishah | Audit report 18 pages | en | Current Exp: 1 Oct 2026 | 89 / 100 | |
Medical Credentialing and Privileging Master Register (2025/2026) doc-08·Uploaded by hs-azmi | Register 52 pages | en | Current Exp: 31 Dec 2026 | 95 / 100 | |
Hospital-wide Mandatory CPD & CPR Competency Training Records doc-09·Uploaded by hs-aishah | Training record 64 pages | enms | Current Exp: 31 Dec 2026 | 91 / 100 | |
Staff Wellbeing & Employee Assistance Informational Leaflet doc-10·Uploaded by hs-aishah | Leaflet 2 pages | enms | Current Exp: 31 Dec 2026 | 22 / 100 | |
Occupational Safety & Health Committee Annual Plan & Workplace Audits doc-11·Uploaded by hs-zaki | Audit report 32 pages | enms | Current Exp: 31 Dec 2026 | 88 / 100 | |
Chemical Safety Data Sheets (SDS) & Clinical Waste Consignment Manifests doc-12·Uploaded by hs-zaki | Register 80 pages | enms | Unlinked | Current Exp: 1 Jun 2027 | 92 / 100 |
Hospital Fire Emergency Plan & Fire Warden Roster (2023/2024 Edition) doc-13·Uploaded by hs-zaki | Policy 24 pages | enms | Stale (>12mo)Expired Exp: 31 Oct 2024 | 58 / 100 | |
Hospital Disaster & Mass Casualty Incident Operational Protocol doc-14·Uploaded by hs-nurul | Policy 48 pages | en | Current Exp: 1 Aug 2028 | 93 / 100 | |
Medical Gas Pipeline System (MGPS) Inspection & Defect Remediation Report doc-15·Uploaded by hs-hakim | Audit report 16 pages | en | Current Exp: 1 Mar 2027 | 84 / 100 | |
Biomedical Equipment Master Asset Inventory & Risk Classification doc-16·Uploaded by hs-hakim | Register 110 pages | en | Current Exp: 31 Dec 2026 | 96 / 100 | |
Planned Preventive Maintenance (PPM) & Electrical Safety Testing Verification doc-17·Uploaded by hs-hakim | Audit report 44 pages | en | Current Exp: 31 Dec 2026 | 95 / 100 | |
Biomedical Breakdown Work Order Logs & Corrective Maintenance Sign-offs doc-18·Uploaded by hs-hakim | Register 36 pages | en | Current Exp: 1 Jun 2026 | 87 / 100 | |
Medical Device Authority (MDA) Safety Alert & Recall Action Dossier doc-19·Uploaded by hs-hakim | Register 22 pages | en | Current Exp: 31 Dec 2026 | 90 / 100 | |
Nursing Clinical Governance Manual & Professional Practice Guidelines doc-20·Uploaded by hs-norliah | Policy 140 pages | en | Current Exp: 1 Jan 2027 | 93 / 100 | |
Inpatient Nursing Initial Assessment & Care Plan Sample Audits doc-21·Uploaded by hs-norliah | Audit report 26 pages | en | Current Exp: 1 Sept 2026 | 91 / 100 | |
Safe Medication Administration & Independent Double-Check Protocol doc-22·Uploaded by hs-norliah | Policy 30 pages | en | Current Exp: 1 Mar 2028 | 94 / 100 | |
Structured SBAR Clinical Handover Protocol & Ward Observation Audits doc-23·Uploaded by hs-norliah | Policy 20 pages | en | Current Exp: 1 Apr 2028 | 92 / 100 | |
Inpatient Fall Risk Assessment & Universal Prevention Protocol (2023) doc-24·Uploaded by hs-norliah | Policy 22 pages | en | Stale (>12mo)Expired Exp: 30 Nov 2024 | 62 / 100 | |
Infection Prevention and Control Committee Charter & Work Plan doc-25·Uploaded by hs-tan | Policy 38 pages | en | Current Exp: 1 Jan 2027 | 95 / 100 | |
WHO 5 Moments Hand Hygiene Direct Observation Audit Dossier (2025) doc-26·Uploaded by hs-tan | Audit report 34 pages | en | Current Exp: 31 Dec 2026 | 92 / 100 | |
Healthcare-Associated Infections (HAI) Surveillance Master Dossier doc-27·Uploaded by hs-tan | Register 46 pages | en | Current Exp: 31 Dec 2026 | 94 / 100 | |
Negative Pressure Isolation Suite Differential Pressure Certification doc-28·Uploaded by hs-tan | Certificate 12 pages | en | Current Exp: 1 Nov 2026 | 96 / 100 | |
Environmental ATP Bioluminescence Surface Hygiene Audit Reports doc-29·Uploaded by hs-tan | Audit report 28 pages | en | Current Exp: 1 Jun 2026 | 76 / 100 | |
Antimicrobial Stewardship (AMS) Formulary & Antibiogram Guide doc-30·Uploaded by hs-tan | Policy 50 pages | en | Current Exp: 31 Dec 2026 | 94 / 100 | |
Hospital Outbreak Management Plan & Communicable Disease Protocols doc-31·Uploaded by hs-tan | Policy 36 pages | enms | Current Exp: 1 May 2028 | 91 / 100 | |
Patient Rights & Informed Consent Governance Policy doc-32·Uploaded by hs-rohani | Policy 24 pages | enms | Current Exp: 1 Aug 2027 | 92 / 100 | |
Patient Modesty, Privacy & Chaperone Guidelines doc-33·Uploaded by hs-rohani | Policy 16 pages | enms | Current Exp: 1 Sept 2027 | 89 / 100 | |
Customer Feedback, Complaints Resolution & Grievance Mechanism doc-34·Uploaded by hs-rohani | Policy 22 pages | enms | Current Exp: 1 Feb 2028 | 90 / 100 | |
Medical Records Archival & Physical Security SOP (2023 Edition) doc-35·Uploaded by hs-mastura | Policy 18 pages | enms | Stale (>12mo)Expired Exp: 30 Sept 2024 | 60 / 100 | |
Clinical Documentation Standards & Medical Record Timeliness Policy doc-36·Uploaded by hs-mastura | Policy 30 pages | en | Current Exp: 1 Jan 2028 | 93 / 100 | |
Electronic Medical Record (EMR) Access Control & Audit Trail SOP doc-37·Uploaded by hs-azman | Policy 26 pages | en | Current Exp: 1 Apr 2028 | 95 / 100 | |
Monthly Medical Record Quantitative Quality & Timeliness Audit Dossier doc-38·Uploaded by hs-mastura | Audit report 40 pages | en | Current Exp: 31 Dec 2026 | 82 / 100 |