Industrial training report: Pusat Perubatan Universiti Kebangsaan Malaysia Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Wilayah Persekutuan Kuala Lumpur

This paper is about management of patient case notes or also called patient medical record at Jabatan Maklumat Kesihatan, Pusat Perubatan Universiti Kebangsaan Malaysia. As everyone know that information contain in medical records is private and confidentially. So it is very important to ensure the security is in the high level. There are two form of medical record that is been used in hospital management nowadays which is paper medical records and electronic medical records. However, PPUKM is still used medical records in the paper-based form and in planning to apply electronic medical records. Other than that, this paper also contains information on how Jabatan Maklumat Kesihatan manage and maintain their medical records in the hospital effectively and efficiently. Functions and descriptions of each department that available at Jabatan Maklumat Kesihatan are also described in detail in this paper.