The Download List

The Download List is a pick of my selected references and resource documents from my collection of references and resource documents related to healthcare in general and to health information management/medical records management specifically, to share with you and which might be of interest to you.

Each link below will open in a new tab of your current window. You can then choose to read online, print, or download for free the reference or resource document and save it to your computer.

ACCREDITATION STANDARDS FOR HOSPITALS
Joint Commission International (JCI)
1 Medical Records Review Form flipbook, JCI Hospital Survey Process Guide, 5th Edition, Effective 1 April 2014
The Malaysian Society for Quality in Health (MSQH)
1 SERVICE STANDARD 7 Health Information Management System, Malaysian Hospital Accreditation Standards, 4th Edition, Effective January 2013
 
SOME SELECTED MALAYSIAN LAWS RELATED TO HEALTH INFORMATION MANAGEMENT / MEDICAL RECORDS MANAGEMENT
1 Act 56 Evidence Act 1950
“An Act to define the law of evidence.”
2 Act 254 Limitation Act 1953
“An Act to provide for the limitation of actions and arbitrations.”
3 Act 586 Private Healthcare Facilities And Services Act 1998
“An Act to provide for the regulation and control of private healthcare facilities and services and other health-related facilities and services and for matters related hereto.”
4 Act 629 National Archives Act 2003
“An Act to provide for the creation, acquisition, custody, preservation,use and management of public archives and public records; and for other matters connected therewith.”
5 Act 709 Personal Data Protection Act 2010
“An Act to regulate the processing of personal data in commercial transactions and to provide for matters connected therewith and incidental thereto.”
 
SOME SELECTED MINISTRY OF HEALTH MALAYSIA GUIDELINES / MANUALS RELATED TO HEALTH INFORMATION MANAGEMENT / MEDICAL RECORDS MANAGEMENT PRACTICES
1 INCIDENT REPORTING & LEARNING SYSTEM: “From Information to Action” Manual, January 2012
This manual maybe used by Health Information Management (HIM) / Medical Records (MR) practitioners to facilitate HIM / MR management to set up systems for identifying, reporting and managing “incidents” i.e. reportable events to provide a basis for which HIM / MR  practitioners concerned can review and further improve on their own event reporting system.
2 Pekeliling Ketua Pengarah Kesihatan Bil 17/2010 Garispanduan Pengendalian Dan Pengurusan Rekod Perubatan Pesakit Bagi Hospital-Hospital Dan Institusi Perubatan Kementerian Kesihatan Malaysia
A Ministry of Health Malaysia guideline in Malay (Bahasa Malaysia) on the practice and management of medical records for public hospitals and institutions issued through the Director General Health Circular No. 17/2010
3 Jadual Pelupusan Rekod Perubatan KKM MOHPAK121.06.(GU) Mac 2007
The standardised medical records retention and disposal schedule for all public hospitals and health facilities in Malaysia was circulated through a MoH circular MOH/PAK/121.06.(GU), Mac 2007 in March 2007 in Malay (Bahasa Malaysia).
 
WORLD HEALTH ORGANISATION (WHO) PUBLICATIONS
1 Medical Records Manual: A Guide for Developing Countries
A World Health Organisation (WHO) Regional Office for the Western Pacific publication “intended to help medical/health record workers in developing countries to develop and manage the medical record/health information service in an effective and efficient manner. It has been written for clerical staff with a basic understanding of medical/health record procedures and is designed to aid medical record officers (MROs) and medical record clerks by describing appropriate systems for Medical Record Departments.”
2 Electronic Health Records Manual for Developing Countries
A World Health Organisation (WHO) Regional Office for the Western Pacific publication “designed as a basic reference for use when exploring the development and implementation of Electronic Health Record (EHR) systems. It provides a general overview, some basic definitions and examples of EHR practices. Also covered are points for consideration when moving towards the introduction of an EHR, some issues and challenges which may need to be addressed and some possible strategies, along with steps and strategies to implementation.”
 
EDUCATIONAL MATERIALS AND BEST PRACTICE GUIDELINES
1 A compilation of educational modules for health records/health information management professionals around the world provided on the web site of the International Federation of Health Information Management Associations (IFHIMA). Go to the Learning Center page of the IFHIMA web site to access the educational modules.

Recent Posts

Global COVID-19 Clinical Characterization Case Record Form

In the wake of COVID-19, I have been thinking how coronavirus data is been captured into a typical medical record. A check around the Internet led me to the World Health Organisation [WHO] recommended rapid clinical characterisation case record form (clinical CRF).

Like the one standardised form i.e. The World Health Organisation (WHO) International Form of Medical Certificate of Cause of Death to collect mortality data among member states—with the clinicial CRF form also by the WHO, the WHO intends that by using one standardised clinical data tool, there is potential for clinical data from around the world to be aggregated; in order to learn more to inform the public health response and prepare for large scale clinical trials.

This form is intended to provide member states with a standardised approach to collect clinical data in order to better understand the natural history of this disease and describe clinical phenotypes and treatment interventions (i.e. clinical characterisation) for Covid-19.

Some important stuff to take note if implementing this form include:

1: this CRF has 3 (M)odules to be completed—(M1)for first day of admission to the health centre, (M2) on first day of admission to ICU or high dependency unit, also be completed daily for as many days as resources allow and continued to follow-up patients who transfer between wards, and (M3) to be completed at discharge or death; and,

2: Internet services are required to enter data to the central electronic REDCap database or to your site/network’s independent database; the form guidelines suggest that printed paper CRFs may be used and the data can be typed into the electronic database afterwards.

The form can be viewed from the link (the link will open in a new tab of your current window) in the reference given below.

Reference:
Coronavirus disease (COVID-19) technical guidance: Patient management, Case Management, WHO, <https://www.who.int/docs/default-source/coronaviruse/who-ncov-crf.pdf?sfvrsn=84766e69_4>

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