Medical Record

Vision

The Medical Records Department will be an effective, efficient information reference center and provide excellent services in the health profession

Mission

Provide quality, complete, effective and efficient health information services and produce trained medical records personnel.

Objective

1. To ensure orderly and updated management of medical records in accordance with established guidelines.

2. To collect and provide accurate, fast and reliable health information

3. To ensure an efficient and systematic medical report management service.

Organisation Chart

Services

1.         Office Hours

1.1       Medical Record Management

• • Maintain patient medical records based on the Guidelines for Handling and Management of Patient Medical Records at KKM Facilities 2023
  • The management of the patient's medical records involves the activities of receiving, binding, storing, borrowing and disposing of records and filed using the Digit Terminal System and Color Code.
  • Separation and disposal of patient medical records according to the procedures in The 2016 Health Ministry Medical Record Disposal Schedule
  • Provide advisory services and monitor the management of patients' medical records under the management of the Clinical Department

1.2       Medical Legal Unit

• • Medical Report Application Management
  • Medical Board Management
  • Case Management Involving Law (Subpoenas & Writs of Summons)

1.3       Health Informatics Unit      

• • Hospital Annual Report
  • Medical Record Information System (SMRP)

(Collect statistical data of inpatients, outpatients, daily treatment and support services)

• • The classification of diseases as well as procedures or surgeries for inpatient cases is based on The International Classification of Diseases and Related Health Problems (ICD) standards.
  • Inpatient data collection along with code classification on the SMRP and Casemix System

1.4       National Indicator Approach

• • Delay data in the preparation of Medical Reports
  • Data on the accuracy of the time period of sending medical records of discharged patients to the Medical Records Department

2.         Out of Office Hours

Tracking Patient Medical Records After Office Hours (On-Call)

Tracking patient medical records after office hours need to be done to meet the requirements of Kuala Lumpur Hospital to achieve Accreditation and ISO. Therefore, the Medical Records Department has established an After Office Hours (On-Call) Patient Medical Records Tracking Team consisting of Medical Records Department staff. This On-Call team has started operations since July 15, 2005 and operates in the Medical Legal Unit (K1), Wisma Rekod.

Extension Number : 6005

Operation hours

Client Charter

Medical Records Department is ready to provide fast, accurate and efficient services to customers :-

• Ensure active patient medical records can be issued within 30 minutes
• The preparation of a medical report for a complete application can be prepared in not more than four (4) weeks (counting working days)
• Ensure that the annual statistical report is accurate, reliable and being prepared before May of the following year.