Last Update: 25 March 2010
DEPARTMENT OF MEDICAL RECORD
Head of Department
Phone
Fax
Email
Puan Noor Aznim Ainy Bt. Ahmad
03-26156078
03-26911681
rekod.hkl@moh.gov.my
I INTRODUCTION I SERVICES I RESEARCH / TRAINING I


Introduction of Department

Medical Records Department is responsible for keeping patient's medical records safely at all times. It's located at Wisma Rekod opposite to Maternity Hospital. It plays an important role in health care institutions as being a referral centre for patient's treatment and care. Success or failure of a health care institution somewhat or rather depends on how well the medical records are managed. More than that, Medical Record Department also handles application for medical report and information as well as documentation.

1. Medical Records Unit at Wisma Rekod:
1.1 Main Medical Records Unit (K2)
1.2 Obstetric & Gynaecology Medical Records Unit (K3)
1.3 Neuroscience Medical Records Unit (K6)
1.4 Arced Medical Records Unit (K4)
2. Medical Records Unit at Clinical Department itself:
2.1 Surgery Medical Records Unit
2.2 Pediatric Medical Records Unit
2.3 Radiotherapy Medical Records Unit
2.4 Urology & Nephrology Medical Records Unit
2.5 Orthopedic Medical Records Unit
3. Medical Records Department act as advisor in management of medical records for the following Departments:
3.1 Dental
3.2 Emergency
3.3 Medical Respiratory
3.4 Nuclear Medicine
3.5 Ophthalmology
3.6 Forensic
3.7 Rehabilitation
3.8 Blood Bank
Vision/Mission

Medical Records Department shall be an effective information centre, efficient and be able to provide excellent and to provide an excellent services in medical profession and to be a model to all hospitals in Malaysia.

Objectives
  1. To build complete, effective, up-to-date and efficient Medical Records Management.
  2. To become a centre in providing accurate, fast, efficient and reliable information.
  3. To provide quality service in processing medical reports and medical board applications.
  4. To build an integrity/unity spirit.
Policies
  1. Medical Records Department operating at office hours.
  2. Medical Records Department is responsible for keeping medical record in a safe place at all time.
  3. Medical Records are prohibited area. No outsider are allowed unless with the authorized permission from the Director/ Head of Department.
  4. Medical Records can not be taken out from the hospital without getting subpoena from the court.
  5. Patient information can not be lead to third party without permission from the patient or legal heir.
  6. All information for education and studies have to get permission from the Director of HKL.
  7. Staffs that work with medical record have to sign 'Confidential Act'.
  8. Patient's medical records which have been discharged must be sent to the Medical Records Department/ Record Office within 72 hours from the date of discharge.
  9. Any information about statistic can not be issued to the public without permission from the director of HKL.
  10. Smoking, eating or drinking are prohibited in the medical record area.
  11. Every medical report application must be through Medical Records Department.