Lampiran 2

PERFORMANCE VERIFICATION FORM PVF: KPI

Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.
DEPARTMENT/
DISCIPLINE GENERAL MEDICINE KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

( OCTOBER) Specific Month

Percentage of patients with waiting time of 90 minutes to see the doctor at General
INDICATOR 2 Medicine Outpatient Clinic

NUMERATOR/ DENOMINATOR
DATA of 154 Fill the number of Case(s)/ 209
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)

STANDARD 90% PERFORMANCE 73.68%

ACHIEVED
.
Data Verification: The Above Performance Data Is
Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

Other (Please Specify in the Other (Please Specify in the

box below) box below)

Jadualukur masa menunggu Klinik PakarRegistration Book

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2
SIQ Yes No NOTIFICATION ACTION
Yes Yes
(If Shortfall in Quality was noted for the above performance, please state
the status in the Notification/ Action Boxes) No No
In progress In progress

Hospital category:
STATE HOSPITAL SPECIALIST HOSPITAL
NON-SPECIALIST HOSPITAL
DECLARATION I:
I hereby certify the above reported performance is verified.
DEPARTMENT/ DISCIPLINE/ UNIT
Officer In-charge of (Name/ Signature/ Designation/ Chop)
the Indicator
(Unit/ Departmental KPI/
Quality Coordinator) (Please fill the date)
d d m
0 4 1

Head of (Name/ Signature/ Designation/ Chop)

Department/ Unit
(State/ Specialist Hospital)
(Please fill the date)
d d y y m
Officer in-
0 4 1 1 2
charged
(Non-Specialist Hospital)

DECLARATION II:
I hereby agree with the above declaration.
HOSPITAL DIRECTOR
Hospital Director (Name/ Signature/ Designation/ Chop)

(Please fill the date)

d d m

FOR THE USE OF HOSPITAL CLINICAL QUALITY UNIT ONLY

PERFORMANCE CONFIRMATION:
The above performance data is certified by the Department/ Unit/ Hospital Director
The data source has been verified by the Department/ Unit/ Hospital Director
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

Other (Please Specify: )

HOSPITAL CLINICAL QUALITY UNIT
Clinical (Name/ Signature/ Designation/ Chop)
Quality Unit
Lampiran 2
Officer In-
(Please fill the date)
charge d d m m y
(Hospital KPI/ Quality
Coordinator)

Page 2/2

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE PAEDIATRIC KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

) Specific Month: (
Percentage of patients with waiting time of 90 minutes to see the doctor at Paediatric
INDICATOR 2 Specialist Clinic.

NUMERATOR/ DENOMINATOR
DATA of 585 Fill the number of Case(s)/ 667
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD 90% PERFORMANCE 87.7%
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

NUMERATOR/ DATA of DENOMINATOR

SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
Other (Please Specify in the Other (Please Specify in the
box below) box below)

Jadualukur masa menunggu Klinik

Registration
Pakar Book

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2
SIQ Yes No NOTIFICATION ACTION
Yes Yes
(If Shortfall in Quality was noted for the above performance, please state
the status in the Notification/ Action Boxes) No No
In progress In progress

Hospital category:
STATE HOSPITAL SPECIALIST HOSPITAL
NON-SPECIALIST HOSPITAL
DECLARATION I:
I hereby certify the above reported performance is verified.
DEPARTMENT/ DISCIPLINE/ UNIT
Officer In-charge of (Name/ Signature/ Designation/ Chop)
the Indicator
(Unit/ Departmental KPI/
Quality Coordinator) (Please fill the date)
d d m
0 4 1

Head of (Name/ Signature/ Designation/ Chop)

Department/ Unit
(State/ Specialist Hospital)
(Please fill the date)
d d m m y
Officer in- 0 4 1 1 2
charged
(Non-Specialist Hospital)

DECLARATION II:
I hereby agree with the above declaration.
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

HOSPITAL DIRECTOR
Hospital Director (Name/ Signature/ Designation/ Chop)

(Please fill the date)

d d m

FOR THE USE OF HOSPITAL CLINICAL QUALITY UNIT ONLY

PERFORMANCE CONFIRMATION:
The above performance data is certified by the Department/ Unit/ Hospital Director
The data source has been verified by the Department/ Unit/ Hospital Director
Other (Please Specify: )
HOSPITAL CLINICAL QUALITY UNIT
Clinical (Name/ Signature/ Designation/ Chop)
Quality Unit
Lampiran 2
Officer In-
(Please fill the date)
charge d d m m y
(Hospital KPI/ Quality
Coordinator)

Page 2/2

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
2 collection.
data of the last term for 3 monthly or 6 monthly frequency of data 0 1 (e.g. 6 Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE GENERAL MEDICINE KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
(Please fill the year)

) Specific Month: (OCTOBER

Percentage of new non-urgent cases that were given appointment for first consultation
INDICATOR 3 within () 6 weeks at General Medicine Outpatient Clinic.
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

NUMERATOR/ DENOMINATOR
DATA of 3 Fill the number of Case(s)/ 3
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD 90% PERFORMANCE 100 %
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
Other (Please Specify in the Other (Please Specify in the
box below) box below)

Buku Temujanji Kes Baru Dirujuk Buku Temujanji Kes Baru Dirujuk

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2

SIQ Yes No NOTIFICATION ACTION

Yes Yes
(If Shortfall in Quality was noted for the above performance, please state
the status in the Notification/ Action Boxes) No No
In progress In progress

Hospital category:
STATE HOSPITAL SPECIALIST HOSPITAL
NON-SPECIALIST HOSPITAL
DECLARATION I:
I hereby certify the above reported performance is verified.
DEPARTMENT/ DISCIPLINE/ UNIT
Officer In-charge of (Name/ Signature/ Designation/ Chop)
the Indicator
(Unit/ Departmental KPI/
Quality Coordinator) (Please fill the date)
d d m
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

1 0 1

Head of (Name/ Signature/ Designation/ Chop)

Department/ Unit
(State/ Specialist Hospital)
(Please fill the date)
d d m m y
Officer in- 1 0 1 0 2
charged
(Non-Specialist Hospital)

DECLARATION II:
I hereby agree with the above declaration.
HOSPITAL DIRECTOR
Hospital Director (Name/ Signature/ Designation/ Chop)

(Please fill the date)

d d m

FOR THE USE OF HOSPITAL CLINICAL QUALITY UNIT ONLY

PERFORMANCE CONFIRMATION:
The above performance data is certified by the Department/ Unit/ Hospital Director
The data source has been verified by the Department/ Unit/ Hospital Director
Other (Please Specify: )
HOSPITAL CLINICAL QUALITY UNIT
Clinical (Name/ Signature/ Designation/ Chop)
Quality Unit
Lampiran 2
Officer In-
(Please fill the date)
charge d d m m y
(Hospital KPI/ Quality
Coordinator)

Page 2/2

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE GENERAL MEDICINE KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

Specific Month: ( 3 MOMTHLY )

INDICATOR 4 Percentage of patients with diabetes who have been screened for target organ damage
DENOMINATOR
NUMERATOR/ 88 Fill the number of Case(s)/ 88
DATA of Patient(s)
SENTINEL EVENT
Fill the number of
Case(s)/ Patient(s)
STANDARD > 70% PERFORMANCE 100 %
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
Other (Please Specify in the Other (Please Specify in the
box below) box below)

Buku Data HPIA/KPI Indicator 4 General Registration

Medication Book

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2
SIQ Yes No NOTIFICATION ACTION
Yes Yes
(If Shortfall in Quality was noted for the above performance, please state
the status in the Notification/ Action Boxes) No No
In progress In progress

Hospital category:
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

STATE HOSPITAL SPECIALIST HOSPITAL

NON-SPECIALIST HOSPITAL
DECLARATION I:
I hereby certify the above reported performance is verified.
DEPARTMENT/ DISCIPLINE/ UNIT
Officer In-charge of (Name/ Signature/ Designation/ Chop)
the Indicator
(Unit/ Departmental KPI/
Quality Coordinator) (Please fill the date)
d d m
0 6 0

Head of (Name/ Signature/ Designation/ Chop)

Department/ Unit
(State/ Specialist Hospital)
(Please fill the date)
d d m m y
Officer in- 0 6 0 7 2
charged
(Non-Specialist Hospital)

DECLARATION II:
I hereby agree with the above declaration.
HOSPITAL DIRECTOR
Hospital Director (Name/ Signature/ Designation/ Chop)

(Please fill the date)

d d m

FOR THE USE OF HOSPITAL CLINICAL QUALITY UNIT ONLY

PERFORMANCE CONFIRMATION:
The above performance data is certified by the Department/ Unit/ Hospital Director
The data source has been verified by the Department/ Unit/ Hospital Director
Other (Please Specify: )
HOSPITAL CLINICAL QUALITY UNIT
Clinical (Name/ Signature/ Designation/ Chop)
Quality Unit
Lampiran 2
Officer In-
(Please fill the date)
charge d d m m y
(Hospital KPI/ Quality
Coordinator)

Page 2/2

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE PAEDIATRICS KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

OCTOBER ) Specific Month: (

Percentage of non-urgent cases that were given appointment for first consultation within
INDICATOR 1 () 6 weeks at Paediatric Specialist Clinic
NUMERATOR/ DENOMINATOR
DATA of 65 Fill the number of 65
SENTINEL EVENT Case(s)/ Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD 80% PERFORMANCE 100%
ACHIEVED
Data Verification: The Above Performance Data Is
Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
Other (Please Specify in the Other (Please Specify in the
box below) box below)

Buku Temujanji Kes Baru Dirujuk Buku Temujanji Kes Baru Dirujuk
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2
SIQ Yes No NOTIFICATION ACTION
Yes Yes
(If Shortfall in Quality was noted for the above performance, please state
the status in the Notification/ Action Boxes) No No
In progress In progress

Hospital category:
STATE HOSPITAL SPECIALIST HOSPITAL
NON-SPECIALIST HOSPITAL
DECLARATION I:
I hereby certify the above reported performance is verified.
DEPARTMENT/ DISCIPLINE/ UNIT
Officer In-charge of (Name/ Signature/ Designation/ Chop)
the Indicator
(Unit/ Departmental KPI/
Quality Coordinator) (Please fill the date)
d d m
0 5 0

Head of (Name/ Signature/ Designation/ Chop)

Department/ Unit
(State/ Specialist Hospital)
(Please fill the date)
d d m m y
Officer in- 0 5 0 2 2
charged
(Non-Specialist Hospital)

DECLARATION II:
I hereby agree with the above declaration.
HOSPITAL DIRECTOR
Hospital Director (Name/ Signature/ Designation/ Chop)

(Please fill the date)

d d m

FOR THE USE OF HOSPITAL CLINICAL QUALITY UNIT ONLY

PERFORMANCE CONFIRMATION:
The above performance data is certified by the Department/ Unit/ Hospital Director
The data source has been verified by the Department/ Unit/ Hospital Director
Other (Please Specify: )
HOSPITAL CLINICAL QUALITY UNIT
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

Clinical (Name/ Signature/ Designation/ Chop)

Quality Unit
Lampiran 2
Officer In-
(Please fill the date)
charge d d m m y
(Hospital KPI/ Quality
Coordinator)

Page 2/2

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE PSYCHIATRY KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

Specific Month: (3 MONTHLY )

Percentage of patients with waiting time of 90 minutes to see the doctor at Psychiatry
INDICATOR 2 Clinic

NUMERATOR/ DENOMINATOR
DATA of 69 Fill the number of Case(s)/ 69
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD 90% PERFORMANCE 100 %
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

DATA SOURCE (Where DATA SOURCE (Where

the primer data can be
traced)
Registration Book (Please
Specify in the box below)
Data from IT System
(Please Specify in the box
below)
Other (Please Specify in the
box below)
the primer data can be
traced)
Registration Book (Please
Specify in the box below)
Data from IT System
(Please Specify in the box
below)
Other (Please Specify in the
box below)

Jadualukur masa menunggu Klinik

Registration
Pakar Book

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2
SIQ Yes No NOTIFICATION ACTION
Yes Yes
(If Shortfall in Quality was noted for the above performance, please state
the status in the Notification/ Action Boxes) No No
In progress In progress

Hospital category:
STATE HOSPITAL SPECIALIST HOSPITAL
NON-SPECIALIST HOSPITAL
DECLARATION I:
I hereby certify the above reported performance is verified.
DEPARTMENT/ DISCIPLINE/ UNIT
Officer In-charge of (Name/ Signature/ Designation/ Chop)
the Indicator
(Unit/ Departmental KPI/
Quality Coordinator) (Please fill the date)
d d m
0 6 0

Head of (Name/ Signature/ Designation/ Chop)

Department/ Unit
(State/ Specialist Hospital)
(Please fill the date)
d d m m y
Officer in- 0 6 0 7 2
charged
(Non-Specialist Hospital)

DECLARATION II:
I hereby agree with the above declaration.
HOSPITAL DIRECTOR
Hospital Director (Name/ Signature/ Designation/ Chop)
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

(Please fill the date)

d d m

FOR THE USE OF HOSPITAL CLINICAL QUALITY UNIT ONLY

PERFORMANCE CONFIRMATION:
The above performance data is certified by the Department/ Unit/ Hospital Director
The data source has been verified by the Department/ Unit/ Hospital Director
Other (Please Specify: )
HOSPITAL CLINICAL QUALITY UNIT
Clinical (Name/ Signature/ Designation/ Chop)
Quality Unit
Lampiran 2
Officer In-
(Please fill the date)
charge d d m m y
(Hospital KPI/ Quality
Coordinator)

Page 2/2

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE PSYCHIATRY KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

Specific Month: ( OCTOBER )

INDICATOR 1 Percentage of non-urgent cases that were given appointment for first consultation within
() 6 weeks at Psychiatry Clinic
NUMERATOR/ DENOMINATOR
DATA of 1 Fill the number of Case(s)/ 1
Patient(s)
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

SENTINEL EVENT
Fill the number of
Case(s)/ Patient(s)
STANDARD PERFORMANCE
80% ACHIEVED 100%

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
Other (Please Specify in the Other (Please Specify in the
box below) box below)

Buku Temujanji Kes Baru Dirujuk Buku Temujanji Kes Baru Dirujuk

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2

SIQ Yes No NOTIFICATION ACTION

Yes Yes
(If Shortfall in Quality was noted for the above performance, please state
the status in the Notification/ Action Boxes) No No
In progress In progress

Hospital category:
STATE HOSPITAL SPECIALIST HOSPITAL
NON-SPECIALIST HOSPITAL
DECLARATION I:
I hereby certify the above reported performance is verified.
DEPARTMENT/ DISCIPLINE/ UNIT
Officer In-charge of (Name/ Signature/ Designation/ Chop)
the Indicator
(Unit/ Departmental KPI/
Quality Coordinator) (Please fill the date)
d d m
0 5 0

Head of (Name/ Signature/ Designation/ Chop)

Department/ Unit
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

(State/ Specialist Hospital)

(Please fill the date)
Officer in- d d m m y

charged 0 5 0 2 2

(Non-Specialist Hospital)

DECLARATION II:
I hereby agree with the above declaration.
HOSPITAL DIRECTOR
Hospital Director (Name/ Signature/ Designation/ Chop)

(Please fill the date)

d d m

FOR THE USE OF HOSPITAL CLINICAL QUALITY UNIT ONLY

PERFORMANCE CONFIRMATION:
The above performance data is certified by the Department/ Unit/ Hospital Director
The data source has been verified by the Department/ Unit/ Hospital Director
Other (Please Specify: )
HOSPITAL CLINICAL QUALITY UNIT
Clinical (Name/ Signature/ Designation/ Chop)
Quality Unit
Lampiran 2
Officer In-
(Please fill the date)
charge d d m m y
(Hospital KPI/ Quality
Coordinator)

Page 2/2

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE PSYCHIATRY KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

Specific Month: ( )

INDICATOR 3 Defaulter rate among Psychiatry outpatient

NUMERATOR/ DENOMINATOR
DATA of 3 Fill the number of Case(s)/ 71
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD <15% PERFORMANCE 4.22%
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
Other (Please Specify in the Other (Please Specify in the
box below) box below)

Registration Book & Appointment

Registration
ListBook

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2

SIQ Yes No NOTIFICATION ACTION

Yes Yes
(If Shortfall in Quality was noted for the above performance, please state
the status in the Notification/ Action Boxes) No No
In progress In progress

Hospital category:
STATE HOSPITAL SPECIALIST HOSPITAL
NON-SPECIALIST HOSPITAL
DECLARATION I:
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

I hereby certify the above reported performance is verified.

DEPARTMENT/ DISCIPLINE/ UNIT
Officer In-charge of (Name/ Signature/ Designation/ Chop)
the Indicator
(Unit/ Departmental KPI/
Quality Coordinator) (Please fill the date)
d d m
0 5 0

Head of (Name/ Signature/ Designation/ Chop)

Department/ Unit
(State/ Specialist Hospital)
(Please fill the date)
d d m m y
Officer in- 0 5 0 2 2
charged
(Non-Specialist Hospital)

DECLARATION II:
I hereby agree with the above declaration.
HOSPITAL DIRECTOR
Hospital Director (Name/ Signature/ Designation/ Chop)

(Please fill the date)

d d m

FOR THE USE OF HOSPITAL CLINICAL QUALITY UNIT ONLY

PERFORMANCE CONFIRMATION:
The above performance data is certified by the Department/ Unit/ Hospital Director
The data source has been verified by the Department/ Unit/ Hospital Director
Other (Please Specify: )
HOSPITAL CLINICAL QUALITY UNIT
Clinical (Name/ Signature/ Designation/ Chop)
Quality Unit
Lampiran 2
Officer In-
(Please fill the date)
charge d d m m y
(Hospital KPI/ Quality
Coordinator)

Page 2/2

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE HPIA: SPECIFIC INDICATOR (KLINIK PAKAR)

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)
Specific Month: (JAN-SEPT)

INDICATOR 7 (NO.7) COLORECTAL CANCER MORTALITY IN THE CORRESPONDING YEAR

NUMERATOR/ DENOMINATOR
DATA of 0 Fill the number of Case(s)/ -
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD NA PERFORMANCE 0
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
Other (Please Specify in the Other (Please Specify in the
box below) box below)

REGISTRATION BOOK REGISTRATION BOOK

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2
SIQ Yes No NOTIFICATION ACTION
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

Yes Yes
(If Shortfall in Quality was noted for the above performance, please state
the status in the Notification/ Action Boxes) No No
In progress In progress
Hospital category:
STATE HOSPITAL SPECIALIST HOSPITAL
NON-SPECIALIST HOSPITAL
DECLARATION I:
I hereby certify the above reported performance is verified.
DEPARTMENT/ DISCIPLINE/ UNIT
Officer In-charge of (Name/ Signature/ Designation/ Chop)
the Indicator
(Unit/ Departmental KPI/
Quality Coordinator) (Please fill the date)
d d m
0 5 0

Head of (Name/ Signature/ Designation/ Chop)

Department/ Unit
(State/ Specialist Hospital)
(Please fill the date)
d d m m y
Officer in- 0 5 0 10 2
charged
(Non-Specialist Hospital)

DECLARATION II:
I hereby agree with the above declaration.
HOSPITAL DIRECTOR
Hospital Director (Name/ Signature/ Designation/ Chop)

(Please fill the date)

d d m

FOR THE USE OF HOSPITAL CLINICAL QUALITY UNIT ONLY

PERFORMANCE CONFIRMATION:
The above performance data is certified by the Department/ Unit/ Hospital Director
The data source has been verified by the Department/ Unit/ Hospital Director
Other (Please Specify: )
HOSPITAL CLINICAL QUALITY UNIT
Clinical (Name/ Signature/ Designation/ Chop)
Quality Unit
Officer In-
(Please fill the date)
charge d d m m y
(Hospital KPI/ Quality
Coordinator)

Page 2/2
 Lampiran 2
PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE RESPIRATORY KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

Specific Month: ( OKTOBER )

Percentage of smear positive PTB patients who are started TB treatment within 3
INDICATOR 2 working days of diagnosis
NUMERATOR/ DENOMINATOR
DATA of 1 Fill the number of Case(s)/ 1
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD 80 % PERFORMANCE 100%
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

Other (Please Specify in the Other (Please Specify in the

box below) box below)

Buku Daftar Kes Tibi Dalam Rawatan

BukuSystem
Daftar Maklumat
Kes Tibi Dalam Rawatan System Maklumat Tibi
Tibi

(Please specify the book name/ - IT

(Please specify the book name/ - IT referral code/ date/ system - file
referral code/ date/ system - file name/ file referral number)
name/ file referral number) Page 1/2

SIQ Yes No NOTIFICATION ACTION

Yes Yes
(If Shortfall in Quality was noted for the above performance, please state
the status in the Notification/ Action Boxes) No No
In progress In progress

Hospital category:
STATE HOSPITAL SPECIALIST HOSPITAL
NON-SPECIALIST HOSPITAL
DECLARATION I:
I hereby certify the above reported performance is verified.
DEPARTMENT/ DISCIPLINE/ UNIT
Officer In-charge of (Name/ Signature/ Designation/ Chop)
the Indicator
(Unit/ Departmental KPI/
Quality Coordinator) (Please fill the date)
d d m
0 6 0

Head of (Name/ Signature/ Designation/ Chop)

Department/ Unit
(State/ Specialist Hospital)
(Please fill the date)
d d m m y
Officer in- 0 6 0 6 2
charged
(Non-Specialist Hospital)

DECLARATION II:
I hereby agree with the above declaration.
HOSPITAL DIRECTOR
Hospital Director (Name/ Signature/ Designation/ Chop)

(Please fill the date)

d d m

FOR THE USE OF HOSPITAL CLINICAL QUALITY UNIT ONLY

PERFORMANCE CONFIRMATION:
The above performance data is certified by the Department/ Unit/ Hospital Director
The data source has been verified by the Department/ Unit/ Hospital Director
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

Other (Please Specify: )

HOSPITAL CLINICAL QUALITY UNIT
Clinical (Name/ Signature/ Designation/ Chop)
Quality Unit
Lampiran 2
Officer In-
(Please fill the date)
charge d d m m y
(Hospital KPI/ Quality
Coordinator)

Page 2/2

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE ORTHOPAEDIC KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

Specific Month: (OCTOBER )

Percentage of non-urgent cases that were given appointment for first consultation within
INDICATOR 1 () 4 weeks at Orthopaedic Clinic.
NUMERATOR/ DENOMINATOR
DATA of 21 Fill the number of Case(s)/ 21
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD 90% PERFORMANCE 100%
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

SENTINEL EVENT Yes No

Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
Other (Please Specify in the Other (Please Specify in the
box below) box below)

Buku Temujanji Kes Baru Dirujuk Buku Temujanji Kes Baru Dirujuk

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2
SIQ Yes No NOTIFICATION ACTION
Yes Yes
(If Shortfall in Quality was noted for the above performance, please state
the status in the Notification/ Action Boxes) No No
In progress In progress

Hospital category:
STATE HOSPITAL SPECIALIST HOSPITAL
NON-SPECIALIST HOSPITAL
DECLARATION I:
I hereby certify the above reported performance is verified.
DEPARTMENT/ DISCIPLINE/ UNIT
Officer In-charge of (Name/ Signature/ Designation/ Chop)
the Indicator
(Unit/ Departmental KPI/
Quality Coordinator) (Please fill the date)
d d m
0 5 0

Head of (Name/ Signature/ Designation/ Chop)

Department/ Unit
(State/ Specialist Hospital)
(Please fill the date)
d d m m y
Officer in- 0 5 0 2 2
charged
(Non-Specialist Hospital)

DECLARATION II:
I hereby agree with the above declaration.
HOSPITAL DIRECTOR
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

Hospital Director (Name/ Signature/ Designation/ Chop)

(Please fill the date)

d d m

FOR THE USE OF HOSPITAL CLINICAL QUALITY UNIT ONLY

PERFORMANCE CONFIRMATION:
The above performance data is certified by the Department/ Unit/ Hospital Director
The data source has been verified by the Department/ Unit/ Hospital Director
Other (Please Specify: )
HOSPITAL CLINICAL QUALITY UNIT
Clinical (Name/ Signature/ Designation/ Chop)
Quality Unit
Officer In- Lampiran 2
(Please fill the date)
charge d d m m y
(Hospital KPI/ Quality
Coordinator)

Page 2/2

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE OTORHINOLARYNGOLOGY KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

Specific Month: ( OCTOBER)

INDICATOR 1 Percentage of patients with waiting time of 90 minutes to see the doctor at
Otorhinolaryngology Clinic
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

NUMERATOR/ DENOMINATOR
DATA of 84 Fill the number of Case(s)/ 84
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD 90% PERFORMANCE 100%
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
Other (Please Specify in the Other (Please Specify in the
box below) box below)

Jadualukur masa menunggu Klinik Pakar Registration Book

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2
SIQ Yes No NOTIFICATION ACTION
Yes Yes
(If Shortfall in Quality was noted for the above performance, please state
the status in the Notification/ Action Boxes) No No
In progress In progress

Hospital category:
STATE HOSPITAL SPECIALIST HOSPITAL
NON-SPECIALIST HOSPITAL
DECLARATION I:
I hereby certify the above reported performance is verified.
DEPARTMENT/ DISCIPLINE/ UNIT
Officer In-charge of (Name/ Signature/ Designation/ Chop)
the Indicator
(Unit/ Departmental KPI/ (Please fill the date)
d d m
Quality Coordinator)
0 4 0

Head of (Name/ Signature/ Designation/ Chop)

Department/ Unit
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

(State/ Specialist Hospital) (Please fill the date)

d d m m y
4 0 5 2
0
Officer in-
charged
(Non-Specialist Hospital)

DECLARATION II:
I hereby agree with the above declaration.
HOSPITAL DIRECTOR
Hospital Director (Name/ Signature/ Designation/ Chop)

(Please fill the date)

d d m

FOR THE USE OF HOSPITAL CLINICAL QUALITY UNIT ONLY

PERFORMANCE CONFIRMATION:
The above performance data is certified by the Department/ Unit/ Hospital Director
The data source has been verified by the Department/ Unit/ Hospital Director
Other (Please Specify: )
HOSPITAL CLINICAL QUALITY UNIT
Clinical (Name/ Signature/ Designation/ Chop)
Quality Unit
Officer In- Lampiran 2
(Please fill the date)
charge d d m m y
(Hospital KPI/ Quality
Coordinator)

Page 2/2

ERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th JPuly of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the
received data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported
performance. This form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be
kept in the Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE GENERAL SURGERY KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

Specific Month: ( OCTOBER )

INDICATOR 1 Percentage of new non-urgent cases that were given appointment for first consultation
within ( )4 weeks at General Surgery Clinic
NUMERATOR/ DENOMINATOR
DATA of 23 Fill the number of Case(s)/ 23
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD 75% PERFORMANCE 100 %
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
Other (Please Specify in the Other (Please Specify in the
box below) box below)

Buku Temujanji Kes Baru Dirujuk Buku Temujanji kes Baru Dirujuk
Lampiran 2

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR dataPage
audit1/2plan.

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my
piran 2

is at least by 15th JPuly of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the
received data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported
performance. This form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be
kept in the Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE RESPIRATORY KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE J ULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

Specific Month: ( OKTOBER)

INDICATOR 1 Percentage of non-urgent cases that were given appointment for first consultation within
( )6 weeks at Respiratory Clinic
NUMERATOR/ DENOMINATOR
DATA of 2 Fill the number of Case(s)/ 2
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD 80% PERFORMANCE 100%
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
Other (Please Specify in the Other (Please Specify in
box below) the box below)

Buku temujanji kes baru dirujuk Buku temujanji kes baru dirujuk

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.
Lampiran 2
DEPARTMENT/
DISCIPLINE GENERAL MEDICINE KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

Specific Month: 3 MONTHLY

INDICATOR 5 Percentage of patients with history of myocardial infarction treated with ALL
named medications

NUMERATOR/ DENOMINATOR
DATA of 7 Fill the number of Case(s)/ 8
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD 70% PERFORMANCE 87.5%
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

Other (Please Specify in the Other (Please Specify in the

box below) box below)

KPI FOR MI BOOK KPI FOR MI BOOK

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
PERFORMANCE VERIFICATION FORM Page 1/2
Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE GENERAL MEDICINE KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)

Specific Month: ( 6 MONTHLY )

Percentage of hypertensive patients with blood pressure 140/90 mmHg as measured
INDICATOR 6 in the General Medication Outpatient Clinic

NUMERATOR/ DENOMINATOR
DATA of 176 Fill the number of Case(s)/ 246
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD 70% PERFORMANCE 71.54%
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

DATA SOURCE (Where DATA SOURCE (Where

the primer data can be
traced)
Registration Book (Please
Specify in the box below)
Data from IT System
(Please Specify in the box
below)
Other (Please Specify in the
box below)
the primer data can be
traced)
Registration Book (Please
Specify in the box below)
Data from IT System
(Please Specify in the box
below)
Other (Please Specify in the
box below)

BUKU DATA HPIA/KPI INDICATOR

BUKU
6 GENERAL
DATA HPIA/KPI INDICATOR 6 GENERAL; MEDICINE
MEDICINE

(Please specify the book name/ - IT

(Please specify the book name/ - IT referral code/ date/ system - file
referral code/ date/ system - file name/ file referral number)
name/ file referral number) Page 1/2
PERFORMANCE VERIFICATION FORM
Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
2 collection.
data of the last term for 3 monthly or 6 monthly frequency of data 0 1 (e.g. 6 Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE SPECIFIC INDICATOR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
(Please fill the year)

Specific Month: ( 6 MONTHLY )

Percentage of hypertensive patients who were under regular clinic follow-up with Blood
INDICATOR 4 Pressure (BP) control 140/90 in the corresponding year

NUMERATOR/ DENOMINATOR
DATA of 266 Fill the number of Case(s)/ 399
SENTINEL EVENT Patient(s)
Fill the number of
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

Case(s)/ Patient(s)
STANDARD 70% PERFORMANCE 66.6%
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
Other (Please Specify in the Other (Please Specify in the
box below) box below)

BUKU PENDAFTARAN MOPD BUKU PENDAFTARAN MOPD

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2

PERFORMANCE VERIFICATION FORM

Filling frequency is depending on data frequency reporting - please refer to the technical specifications OR data audit plan.
NOTE:
IT IS A FORM TO DECLARE THE VALID DATA (VALID SOURCE (TRACEABLE) & VERIFIED)
This form is required to be filled by the Officer in-charge of the Department/ Unit or Specialist/ Consultant/ Head of Department (for
Specialist Hospital) AND by the Officer in-charge of the Clinical Quality Unit/ Hospital Director (for Non-Specialist Hospital) in
certifying the reported performance. It should be sent to the Hospital Clinical Quality Coordinator with at least 7 days before audit is being
conducted. The duration of the collected data to be spelt/ written in the form is suggested not less than 30 days from audit exercise OR
data of the last term for 3 monthly or 6 monthly frequency of data collection. (e.g. Audit is planned on 15 th August, the last data to be recorded
is at least by 15th July of the same year (except 3 monthly OR 6 monthly data reporting last term data). Without this certification, the received
data is considered not valid. In justified circumstances the Hospital Director are given the authority to certify the reported performance. This
form will be taken as reference for Performance Audit Activity. This completed Performance Verification form should be kept in the
Hospital Quality Unit with a copy in the Department/ Unit.

DEPARTMENT/
DISCIPLINE GENERAL MEDICINE KLINIK PAKAR

HOSPITAL HOSPITAL KEPALA BATAS JKN PULAU PINANG

(Please tick to the SELECTED option)

TYPE OF INDICATOR:
KEY PERFORMANCE INDICATOR (KPI) HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY (HPIA)
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my

PERIOD: YEAR:
JANUARY MAC JANUARY JUNE JULY SEPT JULY DECEMBER OTHERS (SPECIFY)
2 0 1 6 (Please fill the year)
Specific Month: ( )
Percentage of patients with non valvular atrial fibrillation assessed for risk of stroke
INDICATOR 7 within () 6 months of diagnosis.
NUMERATOR/ DENOMINATOR
DATA of 4 Fill the number of Case(s)/ 4
SENTINEL EVENT Patient(s)
Fill the number of
Case(s)/ Patient(s)
STANDARD 70% PERFORMANCE 100%
ACHIEVED

Data Verification: The Above Performance Data Is

Verified
NUMERATOR/ DATA of DENOMINATOR
SENTINEL EVENT Yes No
Yes No
DATA SOURCE (Where DATA SOURCE (Where
the primer data can be the primer data can be
traced) traced)
Registration Book (Please Registration Book (Please
Specify in the box below) Specify in the box below)
Data from IT System Data from IT System
(Please Specify in the box (Please Specify in the box
below) below)
Other (Please Specify in the Other (Please Specify in the
box below) box below)

BUKU KPI MI &AF BUKU KPI MI&AF

(Please specify the book name/ - IT (Please specify the book name/ - IT
referral code/ date/ system - file referral code/ date/ system - file
name/ file referral number) name/ file referral number)
Page 1/2
 PERFORMANCE VERIFICATION FORM PVF: KPI
Prepared by: CLINICAL PERFORMANCE SURVEILLANCE UNIT, MEDICAL DEVELOPMENT DIVISION, MOH ver.01A/2014
TEL:03-8883 1180/ 1181/ 1200/ 1203/ 1208/ 1214; FAKS: 03-8883 1176
Any enquiry/ suggestion please e-mail to: amin_sah@moh.gov.my/ nazirpaa@moh.gov.my/ drsitinawal@moh.gov.my/
msuffian.md@moh.gov.my/ norbazeiah@moh.gov.my