Profesion Fisioterapi
Jabatan Kesihatan Negeri Sarawak
Sistem Audit Perkhidmatan Fisioterapi
Bahagian Sains Kesihatan Bersekutu — Kementerian Kesihatan Malaysia
Bahagian Sains Kesihatan Bersekutu — Kementerian Kesihatan Malaysia
Profesion Fisioterapi
Jabatan Kesihatan Negeri Sarawak
Log Masuk Pengguna
Guna akaun Google @moh.gov.my atau email berdaftar
🔐 Akses Admin
JKTFS — Jawatankuasa Teknikal Fisioterapi Sarawak
Anda hanya perlu pilih fasiliti sekali sahaja
Anda hanya perlu pilih fasiliti sekali sahaja
Memuatkan data...
Panduan pengisian Borang Audit Perkhidmatan Profesion Fisioterapi — Bahagian Sains Kesihatan Bersekutu, KKM.
| Perkara Audit | Garis Panduan Pematuhan |
|---|---|
| a. Carta Organisasi | Carta organisasi yang terkini, menunjukkan hubungan pelaporan, disahkan dan bertarikh. |
| b. Visi / Misi | Dipamerkan di kawasan strategik, selaras dengan hospital, disahkan dan bertarikh. |
| c. Objektif Unit | Objektif perkhidmatan fisioterapi yang jelas, boleh diukur, disemak dan dikemaskini. |
| d. Sistem Fail Akreditasi / MS ISO | Fail disusun mengikut kategori dan dikemaskini – akreditasi, statistik, kewangan, latihan, pelajar dll. |
| e. Fail Unit | Fail berikut lengkap dan dikemaskini: peribadi, belanjawan, pekeliling, statistik, pelatih, latihan & CME. |
| f. Piagam Pelanggan | Piagam pelanggan dipamerkan dengan jelas untuk tatapan umum. |
| g. Pengurusan Aduan | Carta alir dan proses pengurusan aduan dipamerkan dan mudah dirujuk. |
| h. Statistik & SMRP | Statistik perkhidmatan direkodkan, dipantau dan dihantar kepada pihak berkaitan. |
| i. Mesyuarat Jabatan / Unit | Fail minit lengkap: surat panggilan, kehadiran, minit, maklum balas, akuan membaca. |
| j. Penyampaian Maklumat | Minit mesyuarat dan maklumat penting dipamerkan atau disebarkan melalui papan kenyataan/unit. |
| Perkara Audit | Garis Panduan Pematuhan |
|---|---|
| a. Polisi Jabatan/Unit | Polisi bertulis yang disahkan dan dikemaskini setiap 3 tahun. |
| b. Bukti Penyampaian | Semua staf menandatangani akuan penerimaan/membaca polisi yang dikemaskini. |
| c. Protokol Rawatan | Protokol rawatan fisioterapi lengkap dan boleh dirujuk. |
| d. Standard Operating Procedure (SOP) | SOP disediakan untuk semua prosedur klinikal dan bukan klinikal. |
| e. Modul Orientasi dan Persetujuan Pesakit | Modul orientasi disediakan untuk staf baharu dan consent form digunakan untuk pesakit. |
| f. Hak dan Privasi Pesakit | Dipamerkan dengan jelas dan dihormati dalam semua interaksi rawatan. |
| Perkara Audit | Garis Panduan Pematuhan |
|---|---|
| a. Penggunaan KEWPA | Borang KEWPA digunakan untuk pemantauan aset dengan betul. |
| b. Fail Pelupusan | Fail lengkap dengan senarai item dilupus dan tarikh kelulusan. |
| c. Penjagaan Aset | Penyelenggaraan berjadual (PPM) dijalankan mengikut jadual dan direkodkan. |
| d. Pengurusan Stor dan Stok | Rekod keluar masuk stok dikemaskini dan disusun secara sistematik. |
| e. Sistem Panggilan Kecemasan | Carta alir Code Blue dipamerkan, sistem berfungsi. |
| f. Tandas OKU | Lengkap dengan grab bar dan loceng kecemasan yang berfungsi. |
| Perkara Audit | Garis Panduan Pematuhan |
|---|---|
| a. Pengumpulan Data NIA/KPI | Senarai indikator, data dikumpul, dipantau, dihantar ke penyelaras negeri |
| b. Semakan Audit Personel | Audit prestasi staf dijalankan secara berkala dan direkodkan. |
| c. Inovasi / QAP / KIK / EKSA | Aktiviti inovasi/kualiti dilaksanakan dan direkodkan. |
| d. Kajian Kepuasan Pelanggan | Dijalankan dua kali setahun, hasil dianalisis dan tindakan penambahbaikan diambil. |
| e. Kajian Piagam Pelanggan | Sekurang-kurangnya sekali setahun, kaji keberkesanan piagam pelanggan. |
| f. Latihan Keselamatan dan Kesihatan | Semua staf hadiri latihan kebakaran, BLS, kawalan jangkitan, dan latihan bencana. |
| g. Laporan Insiden & RCA | Semua kejadian dilaporkan, disiasat, ada tindakan pembetulan dan pencegahan. |
| h. Penilaian HIRARC | Penilaian risiko untuk prosedur rawatan berisiko disediakan dan dikaji semula. |
| Perkara Audit | Garis Panduan Pematuhan |
|---|---|
| a. Surat Lantikan Ketua Unit | Disimpan bersama deskripsi tugas rasmi. |
| b. MyPortfolio | Dikemaskini, mengandungi peranan dan tanggungjawab staf. |
| c. Surat Lantikan AJK/Jawatankuasa | Salinan surat pelantikan disimpan dan dikemaskini. |
| d. Sijil Pendaftaran MAHPC | Semua fisioterapis berdaftar dengan MAHPC dan sijil dikemaskini. |
| e. Orientasi Anggota Baharu | Pelaksanaan program orientasi lengkap dengan senarai semak dan kehadiran. |
| f. Fail CPD | Rekod kursus, latihan dan CME setiap staf direkodkan. |
| g. Credentialing / Privileging | Dilaksanakan bagi Optional/Advance Procedure |
| h. Program Mentor / Kompetensi | Jadual penyeliaan, laporan prestasi dan program mentor/kompetensi direkodkan. |
| i. Perancangan Kursus Tahunan | Pelan latihan tahunan disediakan dan dilaksanakan. |
| j. Jadual Tugas | Jadual harian/bulanan dikemaskini, adil dan mengikut keperluan semasa |
| k. Pengurusan Cuti | Fail serta rekod permohonan dan kelulusan cuti lengkap dan dikemaskini. |
| l. Etika Pemakaian | Kakitangan berpakaian mengikut pekeliling kerajaan dan peraturan sedia ada. |
Panduan pengisian Borang Audit Dokumentasi Klinikal Profesion Fisioterapi — Bahagian Sains Kesihatan Bersekutu, KKM.
| No. | Item | Panduan Pengisian |
|---|---|---|
| 1. | Appropriate Assessment Form Used | Use the correct assessment form based on the patient category (e.g., adult neuro, musculoskeletal, pediatrics). |
| 2. | Presenting Condition | Clearly describe the patient’s primary complaint or referral reason. |
| 3. | Pain Documentation | State type, intensity (VAS/NRS/Wong Baker), location, nature (burning, stabbing), and aggravating/relieving factors. |
| 4. | Body Chart | Use the body chart to mark pain, numbness, stiffness, weakness, etc., with brief explanations. |
| 5. | Special Questions | Include questions related to general health, red flags, medications, bladder/bowel issues, weight loss, etc. |
| 6. | Current History | Explain how the condition began – onset, mechanism of injury, acute vs chronic. |
| 7. | Past History | Describe any previous episodes of similar issues or other medical history relevant to current problem. |
| 8. | Observation | Note posture, gait, facial expressions, swelling, scars, or other visual indicators. |
| 9. | Palpation | Include findings such as tenderness, spasm, warmth, crepitus, or abnormal muscle tone. |
| 10. | Assessment Tools | Use and record objective tools such as ROM, MMT, Oswestry, MAS, etc., with findings. |
| 11. | Physiotherapist’s Impression | Summarise findings, interpret the problem, prioritise issues, and give clinical impression. |
| 12. | Goals | State both short- and long-term treatment goals that are SMART and patient focused. |
| 13. | Treatment Plan | Document planned intervention strategies based on findings and goals. |
| 14. | Informed Consent | Record that patient has given verbal or written consent. May include signed form or note in the record. |
| 15. | Intervention Implementation | Confirm that treatment provided is aligned with treatment plan. |
| 16. | Advice / Information Given | Include home exercise instructions, posture education, precautions, etc., with documented evidence. |
| 17. | Subjective Markers Reviewed | Note pain changes, functional limitations, and subjective reports in each session. |
| 18. | Objective Markers Reviewed | Reassess ROM, strength, function etc., during follow-ups. Record the progress. |
| 19. | Problem Analysis | Discuss clinical reasoning based on findings. Use ICF model or others if applicable. |
| 20. | Treatment Plan Revision | Clearly document any changes in treatment plan with rationale. |
| 21. | Discharge Plan | Include discharge criteria, plan for follow-up or referrals, and education. |
| 22. | Documentation of Every Visit | Every visit must be documented using SOAP format |
| 23. | Documentation Quality | Ensure entries are: • Concise • Legible • In logical sequence |
| 24. | Signature & Stamp | Every entry must be signed, stamped (with MAHPC Number), and dated by the treating physiotherapist. |
| No. | Item | Panduan Pengisian |
|---|---|---|
| 25.1 | Standard Operating Procedures (SOP) | Ensure the unit has access to all 8 core SOPs (e.g., Neuro, MS, Geriatric, Respiratory, Sports Injury, Pediatrics, Urinary Incontinence, Operational Management). Staff should be familiar with the content and application of each. During audit, provide SOP files (hardcopy or digital) and show how they are applied in clinical practice. |
| 25.2 | Physiotherapy Care Protocols | Care protocols should reflect evidence based practices endorsed by the Physiotherapy Technical Committee. Guide standardised management for specific conditions (e.g., stroke, ACL injury). Ensure they are updated, available, and used as reference in assessments and treatment planning. |
| 25.3 | Best Statements | Best Statements are concise, practical clinical guidelines created for specific practices or conditions . Staff should be able to show awareness and apply relevant Best Statements during patient care. Ensure documentation reflects adherence. |
Kawalan akses pengguna dan keselamatan sistem
● Password disimpan dalam peranti ini (localStorage) sahaja.
● Jika anda log masuk dari peranti lain, password asal Audit2026 digunakan.
● Untuk password kekal keseluruhan sistem, kemaskini kod dalam fail index.html.
Jana laporan mengikut kategori, fasiliti dan sesi