Definition Of Medical Reports

Medical reports are reports that are prepared by a medical practitioner or registered dentist who is in service with the Malaysian Government pertaining to the health problems and the treatment given to a patient, based on the patient’s medical record in a hospital or any other health institution.

Category Of Medical Reports

1. Medical report prepared by the medical officer
2. Short Report/Opinion prepared by a specialist
3. Detailed medical reports prepared by a specialist

(Note: Medical Examination, confirmation of medicine for People with disabilities (PWDs), Welfare Assistance, assistance of Zakat, Sara Form drug (SFD) and sick leave are not included in the category of medical reports).

Application Procedure

Medical report request can be made by the applicant through post or in person at the hospital’s medical records department, where the patient was getting treatments. Medical reports will only be processed once a complete application is submitted.

Documents Required For the Application of Medical Reports

1. Every application for medical reports must be accompanied by the following documents:

• Application letter written or using the KKMLP/1/2008 form.
• The ORIGINAL Consent Letter permitting the hospital to issue a report to the related person. The letter must be signed by the patient / beneficiary patient’s valid (husband/wife/daughter/mother/father/ siblings.
• The fee for the medical reports is in accordance with the type of the medical report requested.
• A copy of identity card of the patient.
• A copy of patient’s treatment appointment card.
• Insurance claim forms or other claim form by the patient. (Insurance, EPF, Labour 90, SOCSO

2. For patients under the age of 18, the application shall be made by mother / father / legal guardian by attaching the following documents:

• All documents mentioned in paragraph 1.
• ORIGINAL consent letter from the parent / legal guardian.
• A copy of the birth certificate of the patient.
• A copy of the identity card of the parent / legal guardian

3. For medical reports of patients who have died, applications can be made by husband or wife / children / mother / father / same father’s siblings of patients by including documents such as follows:

• All documents mentioned in paragraph 1.
• A letter of consent from the ORIGINAL beneficiary (stating the beneficiary information).
• A copy of identity card of the deceased.
• A copy of the identity card of the beneficiary.
• A copy of the marriage certificate (if applicable).
• A copy of birth certificate (if applicable).
• A statutory declaration (if applicable).
• A copy of Burial Permit / death certificate.

4. Medical report application can be made through agents / representatives (insurance, lawyers and others) with condition in which the applicant provides the original letter of consent of patient / beneficiary to give the authorisation to the agent / representative to apply for the medical report.

Letter of Consent

The consent letter is a document signed by the patient or the patient’s legal heirs that permits the hospital to issue a medical report to a third party who require the report. The letter of consent is exempted to:

• The Royal Malaysian Police.
• The Malaysian Courts.
• Any agencies that have been authorized under provisions under the law to obtain the patient medical report without the consent from the patient / beneficiary.

The Beneficiary

The beneficiary is the person that eligible to sign a letter of consent for behalf of the patient, they are husband/wife/children/legal guardian/siblings of the patients only. Foreign patients who have died or have returned to their respective countries, a letter of consent must be signed and confirmed by the embassy of the relevant country.

The Medical Report Fee

Fee charged to applicants for one (1) medical report shall be as specified in the Fees Order (Medical) 1982 and Fees Order (Medical) Amendment 2003 – for foreigners.

Repeated Application:

Exemption

• The Royal Malaysian Police.
• Government departments (for administrative purposes).
• Patients that obtain declaration letter from the Social Welfare Department with a Social Welfare Department registration card.
• Legal Aid Bureau.
• BAT F117 form for the army accompanying with endorsement letter from the commanding officer.

The Client Charter

The period for the preparation of the medical reports are calculated from the date of the complete application at the Department/ medical records unit to the date of completion of the report prepared by the assigned medical officer. Period of preparation has been determined in accordance with General Director of Health Bill 16/2010 circular: Guidelines for the preparation of medical reports In Hospitals & medical institutions as follows:

• State Hospital and Hospital although specialized = not more than 4 weeks
• District Hospital = not more than 2 weeks

(A period of the provision includes weekends and public holidays)

The Process Of Preparing Medical Reports By Period

The process of preparing medical reports according to the fixed period is as follows:

The Causes Of Delay In The Preparation Of Medical Reports

Among the causes of delay in the preparation of medical reports are as follows:

• Delay in tracing the medical records of the patients.
• Delay in delivering the application documents and medical records to the medical officers that concerned.
• Delay in the preparation of medical reports by Medical Officers.
• Patients are still on follow up treatment prior to the application made.

Steps To Speed Up The Process For Medical Reports

Among the steps to expedite the preparation of medical reports are as follows:

• Ensure that the form/application letter contains accurate patient’s information in order to avoid delay in patient record tracking.
• Ensure all the medical record storage system is in order and easy to trace.
• Ensure that the medical records needed are tracked within the specified period.
• Submission of the required documents to the medical officer through officer that was appointed in each clinical department is performed within the time set.
• The date each application and documents submitted to the medical officer must be registered to be completed by the concerned officers.
• Monitor the process of report preparation continuously.

Reference

1. Circular of the General Health Director Bill 16/2010: The preparation of the Medical report in the hospitals & medical institutions guidelines.