English
MalayDepartment of Medical Record
Department of Medical Record is one of clinical support services at Sultan Ahmad Shah Medical Centre @IIUM (SASMEC @IIUM). This department takes responsibility for overseeing and managing both physical and electronic medical records, ensuring strict compliance with the standards established by the Ministry of Health.
To manage, protect and optimize medical records, ensuring their accuracy and accessibility to the highest standard of privacy and compliance.
To develop the Department of Medical Record as an information Centre with comprehensive information to achieve customer satisfaction.
Medical report is a document prepared by a Registered Medical or Dental Practitioner who is employed by the Government of Malaysia (Fee Act 1951, Fee (Medical) in 1982) on health problems and treatment to any patient in hospital or any health facility based on the patient’s medical history (Medical Report Guideline of the Malaysian Medical Council, January 2007).
Application category:
A. Types of medical report application
- Medical report
- Medical questionnaire form
- Post mortem report
- Specialist medical report
- Specialist detailed medical report
- Specialist post mortem report
B. Types of verification for clinical record application
- Medical certificate
- Maternity declaration
- Birth declaration
- Borang daftar kematian (JPN LM 02)
- Perakuan pegawai perubatan sebab kematian (JPN LM 09)
- Memo of attendance
- Discharge summary
- Medical report
C. Types of amendment for clinical record
- Maternity declaration
- Birth declaration
- Borang daftar kelahiran (JPN LM 01)
- Borang daftar kematian (JPN LM 02)
- Perakuan pegawai perubatan sebab kematian (JPN LM 09)
- Perakuan pegawai perubatan sebab kematian (Post Mortem) (JPN LM 10)
- Medical report
• Manages application of borrowing the physical medical records and electronic medical records from physicians, students, and researchers for reference and research purposes
• Provides and prepare the medical records request by wards and clinics
• Storage and issuing the medical records
• Separate semi-active medical records
• Dispose obsolete medical record according to disposal schedule by Ministry of Health (MOH)
• Prepare clinical forms requested by the clinical departments
• Monitor and ensure the quantity of clinical forms are adequate for the hospital operations
• Provide and prepared statistical report for outpatient and inpatient of Sultan Ahmad Shah Medical Centre @ IIUM monthly for the administrative, research and educational purposes
• Sorting, organize and scanned all the medical records received from clinics and wards
• Upload the scanned medical records in the system according to registration number
• Manage digital medical records in the digital storage
• Preparation of diagnosis codes for each patient based on International Statistical Classification of Diseases (ICD-10)
• Notification of communicable disease and cancer to external agencies
All applications can be made by 2 (two) methods:
- Walk in to Medical Records Department counter (Level 1)
- Dispatch by courier service to :
DEPARTMENT OF MEDICAL RECORD (LEVEL 1)
Sultan Ahmad Shah Medical Centre @IIUM,
Jalan Sultan Haji Ahmad Shah, Bandar Indera Mahkota,
25200 Kuantan, Pahang Darul Makmur.
Tel: 09 591 2581
Remark: We are not be liable for any loss or damage of documents
CHECKLIST DOCUMENT FOR APPLICATION OF MEDICAL REPORT / VERIFICATION OF CLINICAL DOCUMENT
| A. | APPLICATION BY PATIENT |
|---|---|
| 1. | ORIGINAL consent letter from patient |
| 2. | Copy of identity card |
| 3. | Copy appointment card / discharge summary |
| B. | APPLICATION BY PARENTS/GUARDIAN |
|---|---|
| 1. | ORIGINAL consent letter from legitimate parent @ guardian |
| 2. | Copy of patient’s MyKid |
| 3. | Copy of patient’s identity card |
| 4. | Copy of parent’s @ guardian’s identity card |
| 5. | Copy appointment card / discharge summary |
| C. | APPLICATION BY NEXT OF KIN (Only valid from Husband/Wife/Child/Siblings & Parent) |
|---|---|
| 1. | ORIGINAL consent letter from patient |
| 2. | Copy of applicant’s identity card |
| 3. | Copy of patient’s identity card |
| 4. | Copy of patient’s MyKid |
| 5. | Copy of patient’s death certificate (if applicable) |
| 6. | Copy of marriage certificate (if applicable) |
| 7. | Letter of statutory declaration (if applicable) |
| 8. | Copy of divorce certificate (if patient is divorced) |
| 9. | Copy of appointment card / Discharge summary |
| D. | APPLICATION BY AGENT / REPRESENTATIVE |
|---|---|
| 1. | ORIGINAL consent letter from patient |
| 2. | Copy of applicant’s identity card |
| 3. | Copy of patient’s identity card |
| 4. | Copy of appointment card / Discharge summary |
| 5. | Copy of patient’s death certificate (if applicable) |
MEDICAL REPORT CHARGES
Remarks:
- For application of medical questionnaire form, kindly provide the forms from respective agencies (if applicable)
- Payment by company cheque must be made in the name of INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA.
- Payment by online banking can be made at our AMBANK (Account No.: 888 101 535 6676) in the name of INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA.
- Exemption of payment covers on applications from the Police (excluding for insurance and EPF purposes), Government Departments and Statutory Bodies (for administrative purposes) and the Legal Aid Bureau.
- Patient can apply a medical report from a different clinical department and each of medical report will be charged separately.
- Each application for clarification or amendment will be counted as a new application and must be complete with all documents needed. Applications must be made through the Medical Records Department, NOT directly to the department or to the Medical Officer or Specialist. No charge is imposed for the purpose of this application.
| Types of Application | Completion Period |
|---|---|
| Medical Report | The period for preparation of medical report is within 30 WORKING DAYS from the date of complete application with payment received and verify by our Finance Department. However, the period of preparation of this report depends on the Medical Officer or Specialist who is responsible for preparing. |
| Verification | The period for preparation of verification is within 7 WORKING DAYS from the date of complete application with payment received and verify by our Finance Department. |
| Amendment | The period for preparation of verification is within 7 WORKING DAYS from the date of complete application. |
Patients in Sultan Ahmad Shah Medical Centre @IIUM have only one medical record file that combines all their health information from all departments (Example: Orthopedic, Surgery, Medical & etc.) which this file will be used for reference to make medical reports, appointments and patient admission to the ward.
Therefore, for applications for more than one department, the preparation period of the medical report will take longer as the report must be completed one by one by Medical Officer or Specialist from different departments.
| Contact Number | 09 591 2581 |
| This email address is being protected from spambots. You need JavaScript enabled to view it. | |
| Address | Department of Medical Record (Level 1) Sultan Ahmad Shah Medical Centre @IIUM, Jalan Sultan Haji Ahmad Shah, Bandar Indera Mahkota, 25200 Kuantan, Pahang Darul Makmur. |
Department of Medical Record
- Level1, Sultan Ahmad Shah Medical Centre @IIUM,
Jalan Sultan Ahmad Shah, Bandar Indera Mahkota,
25200 Kuantan, Pahang. - +609 591 2581
- This email address is being protected from spambots. You need JavaScript enabled to view it.
Sultan Ahmad Shah Medical Centre @IIUM
(609) 591-2500 
(609) 591-2699 