Medical Record

Introduction Medical record is a compilation of information related to health examination and treatment given to a patient. It includes documented data on present and past illnesses as well as treatment by healthcare personnel caring for the patient. The purpose of the medical record is to record the facts or …

Introduction Medical report is a document prepared by a registered medical practitioner or registered dental practitioner who served the Government of Malaysia (Fees Act 1951, Fees (Medical) Order 1982) on health problems and treatments received by a patient in a hospital or any health facilities based on patient’s medical record. …

ICD-9-CM Another Challenge And Responsibility to Medical Records Personal in Ministry Of Health Hospitals. Introduction ‘The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)’ was originally based on the original version developed by the World Health Organization. ICD-9-CM is structured into 3 volumes: Volume I (Tabular list of diseases)           …

Introduction In any hospital or Healthcare facility, the episode of treatment and care must be documented and has become an integral element in Healthcare Service Delivery which emphasizes on continuous and more effective care. The documented information becomes an important reference for Medical Practitioners whereby information which is accurate and …