Medical Record

Introduction

Medical Records Department UiTMMSC Sungai buloh is situated at level 4, Academic Building, Sungai Buloh Campus and UiTMMSC Selayang at level 6 Clinical Building, Selayang Campus. It is under clinical support services, with activities including patients’ medical records and patients’ information management, medical reports management, hospital statistics and all aspects related to hospital information management

Customer Charter

Client / patient dealing with Medical Record will be treated friendly and efficiently
Medical reports application will be processed and completed within 2-4 weeks from the date of application.
Requisition of patient case note will be processed within 5-10 minutes
Monthly statistics will be completed before 15th day in every month
Patients are assured that all medical records and information about the disease and treatment will be kept confidential, stored securely and only be accessible to the third parties with the authorization subjected to the law

Organization Chart

org chart

Services

  • Medical Record Management
  • Receiving, borrowing, returning, updates, binding and storage of medical record
  • Providing service for patient case note for further treatment, research and education.
  • Disposal of inactive medical record in accordance with the Ministry of Health Medical Records Disposal Schedule MOHPAK121.06. (GU) issued in March 2007
  • Information and Documentation Management
  • Collection of data from all clinical department for hospital statistic
  • Preparing monthly and yearly clinical statistic for UiTMMSC Sungai Buloh and Selayang
  • Preparing mortality report
  • Notification of infectious diseases, cancer cases, to the authorities concerned  such as District Health Office
  • Providing clinical statistic required by the Ministry of Health and Ministry of Higher Education
  • Preparing Clinical Coding to all discharged patient according to IC-10 & ICD-9CM handbooks
  • Provide assistance in research related to patient information
  • Medical Report Management
  • Medical report/ insurance claim/KWSP/SOCSO application
  • Medical Board application
  • Specialist report
  • Clarification of medical leave certificate
  • Administration Management
  • Coordinating requisition for Medical Certificate (MC) and time slip at wards and clinic
  • Manage the new clinical form application
  • Printing and supplying clinical forms for both Sg Buloh and Selayang

Application of medical report

Basic requirement for medical report application are:

  • Complete application form (form available at record office)
  • Consent form by patient
  • Related claim form (insurance claim form, EPF, SOCSO, etc)
  • Copy of patient identitification card

Charges

  • Simple Medical Report (prepared by Medical Officer) – RM40
  • Specialist Medical Report (prepared by specialist/ consultant doctor) – RM80
  • EPF (KWSP) Report – RM80
  • SOCSO (PERKESO)– RM80
  • Insurance claim – RM 100
  • insurance policy – RM120
  • Psychology report – RM10 – RM200
  • Comprehensive Specialist Report – RM200-RM1000

(Medical report charges for foreigners is double)

The time frame for the report to be ready is within 4 weeks

Gallery

Industrial training from Faculty of Information Management UiTM Puncak Perdana.
Industrial training from Faculty of Office Management UiTM Puncak Alam
Industrial training from Faculty of Education & Social Science UNISEL
Class visit from UNISEL