Criterion | Self-rating | Surveyor rating | Divergence | Evidence | Person in charge | Last updated |
|---|---|---|---|---|---|---|
13.1.1.11 Labour Ward Triage Protocol 1.1 | Fully met | Fully met | — | None | Matron Norliah binti Hashim | 2026-01-11 |
13.1.2.12 Fetal Heart Monitoring Protocol 1.2 | Not applicable | Not applicable | — | None | Matron Norliah binti Hashim | 2026-01-12 |
13.1.3.13 Obstetric Emergency Response Protocol 1.3 | Fully met | Fully met | — | None | Matron Norliah binti Hashim | 2026-01-13 |
13.1.4.14 Newborn Delivery Protocol Protocol 1.4 | Partially met | Partially met | — | None | Matron Norliah binti Hashim | 2026-01-14 |
13.2.1.15 Birthing Room Hygiene Protocol 2.1 | Partially met | Partially met | — | None | Matron Norliah binti Hashim | 2026-01-15 |
13.2.2.16 Labour Ward Triage Protocol 2.2 | Fully met | Fully met | — | None | Matron Norliah binti Hashim | 2026-01-16 |
13.2.3.17 Fetal Heart Monitoring Protocol 2.3 | Fully met | Fully met | — | None | Matron Norliah binti Hashim | 2026-01-17 |
13.2.4.18 Obstetric Emergency Response Protocol 2.4 | Partially met | Partially met | — | None | Matron Norliah binti Hashim | 2026-01-18 |
13.3.1.19 Newborn Delivery Protocol Protocol 3.1 | Fully met | Fully met | — | None | Matron Norliah binti Hashim | 2026-01-19 |
13.3.2.20 Birthing Room Hygiene Protocol 3.2 | Partially met | Partially met | — | None | Matron Norliah binti Hashim | 2026-01-20 |
13.3.3.21 Labour Ward Triage Protocol 3.3 | Fully met | Fully met | — | None | Matron Norliah binti Hashim | 2026-01-21 |
13.3.4.22 Fetal Heart Monitoring Protocol 3.4 | Fully met | Fully met | — | None | Matron Norliah binti Hashim | 2026-01-22 |
13.4.1.23 Obstetric Emergency Response Protocol 4.1 | Partially met | Partially met | — | None | Matron Norliah binti Hashim | 2026-01-23 |
13.4.2.24 Newborn Delivery Protocol Protocol 4.2 | Fully met | Fully met | — | None | Matron Norliah binti Hashim | 2026-01-24 |