Keep one index of every criterion, the evidence of compliance it names, and where that evidence lives. Leave live records where the work happens, put historical documents in one room, and make every rating traceable to something a surveyor can open.
What a surveyor does with your evidence
Surveyors compare the clinic's documented self-assessment with physical findings, interview the person in charge of each area and some staff, observe the actual workflow, and make a random review of the documentation behind each rating.1 MSQH asks for the documents a survey team reviews to be placed in a secured room near the team, while current records such as health records and dispensing records may stay at the place of work.1
Three kinds of evidence
| Kind | Examples | Where it lives |
|---|---|---|
| Documents | Policies, SOPs, organisation chart, minutes for the year before the survey | The survey room, indexed |
| Live records | Health records, appointment register, prescriptions, consent, complaints | The clinical system, opened on request |
| People | The person in charge and staff, answering for each area | Interviews on the day |
The clinic standards ask for records as evidence again and again, completeness of medical records, a patient register, lists of urgent cases, incident reports with analysis and action, samples of complaints and the action taken.2
- Build the index. One row per criterion, with the evidence of compliance MSQH names for it and where it lives.
- Separate live from historical. Live records stay in the system where they are made. Historical documents go into the survey room.
- Sample before they do. Pull ten records at random and check each against the criteria for information, consent and signature.
- Time the retrieval. Ask a colleague for five items from the index, and time how long each takes to produce.
- Fix the gaps. Anything that takes more than a few minutes, or cannot be found, goes back to its owner.
- Keep it current. Update the index after every quality activity, complaint review and policy review.
- Standard ______ Criterion ______
- Evidence of compliance named by MSQH ______
- Document or record ______ Location ______
- Live or historical ______ Owner ______
- Retrieved in minutes ______ Last checked ______
Next, what happens on the survey day. The MOH and MSQH hub shows where each kind of evidence lives in the clinic.
Questions
Do health records have to be brought to the survey room?
No. MSQH allows current records such as health records and dispensing records to stay where the work happens, so service is not disrupted.
Can a surveyor ask for documents not on the list?
Yes. MSQH says its list is not exhaustive, and surveyors may request more to validate the level of compliance.
How far back should minutes go?
MSQH asks for minutes of meetings for the year before the survey, with terms of reference, membership and frequency.
Sources
- 1Malaysian Society for Quality in Health, 2024Medical Clinic Accreditation Survey Process Guide, March 2024Read source
- 2Malaysian Society for Quality in Health, 2024Medical Clinic Standards, 2nd editionRead source
Written by the wai team from the Ministry of Health Malaysia and the Malaysian Society for Quality in Health guidance, checked on 16 October 2026. This is guidance, not legal advice. Neither the Ministry of Health nor MSQH endorses wai or any software.