Page 11 - Law And Rules Regarding Medical Record

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i. Proper

Documentation

• Proper documentation of case notes,
lab results, x-ray etc.

• Although there are no legislations in

Malaysia to compel doctors/hospitals

to give these documents to the

patient, in the event that they are
required to release these documents

when the case goes for trial,

nonproduction will be detrimental to
the case.

Example of Electronic Patient’s Report