Medical Record Services
Medical Record Services is a support service whose primary purpose is to contribute to the quality of patient care through the development and maintenance of a comprehensive centralized Medical Record system. Services and functions shall be developed and implemented in such a way that confidentiality, privacy, and data security considerations are respected at all stages of the healthcare information gathering and processing.
KPJ Miri Medical Record Scope of Services:
The centralized Medical Record Services shall provide functional support to the healthcare facility with respect to health information services to include:
- Patient identification and numbering system
- Monitoring of clinical record documentation.
- Diagnosis and procedure coding utilizing ICD10.
- Storage and retrieval system, including record tracking.
- Assistance in complying with legal and regulatory provisions and accrediting agency standards concerning health care Data.
- Data security, privacy, and confidentiality processes.
How to Request Your Medical Records:
The Medical Record Services facilitates the release of medical information to our patients.
Medical information is released in the form of medical reports, patient discharge summary, and selected investigation reports. The release of medical information is subject to official approval.
1. WHAT IS REQUIRED DURING THE REQUEST FOR MEDICAL INFORMATION?
A) Patient's written consent for release of medical information to allow the hospital to release medical information for a stated purpose.
- - For patients below 21 years of age, consent of the parent is required.
- - For deceased patients, consent from the appointed representative of the estate is required.
- - Where applicable, the "Consent for release of medical information for deceased patient by all children / all siblings" must be filled up.
- - A copy of the death certificate and other supporting documents, e.g. marriage certificate and letters of administration, are required as proof of the representative's relationship to the patient.
B) A copy of the patient's NRIC / identification documents.
C) A payment for the information required.
D) Cheques are to be crossed and made payable to "Miri Specialist Hospital Sdn Bhd”.
2. WHEN CAN THE REQUESTED MEDICAL INFORMATION BE READY?
As a general guide, the time frame for completion of medical reports is within 14 working days.
It may take longer if:
- Patient has upcoming clinic appointments
- Patient has been hospitalized
- Multiple reports are required from several clinical departments
- Doctor is away
3. HOW WILL I RECEIVE THE MEDICAL REPORT / COPIES OF MEDICAL RECORDS?
Patients can request for the medical report to be:
- Mailed to them (Mailing address to be provided at the point of application)
- For personal collection at Customer Service Counter / Medical Record Services, the patient's contact number is to be provided at the point of application.
- The patient will be contacted once the report is ready for collection.
- NRIC of patient and payment receipt to be produced upon collection.
- Authorisation letter is required if a third party is collecting on patient's behalf.
4. HOW CAN I CONTACT MEDICAL RECORD SERVICES?
Address:
KPJ Miri Specialist Hospital
Medical Record Services
Lot 8836, Block 11
Kuala Baram Land District
Bandar baru Permyjaya
98000 Miri, Sarawak
Tel: 085 – 649 999 EXT: 412(MR1), 413(MR2)