Industrial training report: Medical Record Department, Hospital Selayang / Tuan Hailalmizan Tuan Mat

Medical Records is important part Q/ a patient's present and future health care. Medical records are used essentially for the present and continuing care Q/ the patient. Medical workers professional will write up medical records so that previous medical information is available when the patient returns to the Hospital. The medical record must therefore be available. Medical record worker must ensure that patient medical record can be located, not the patient may suffer because information which could be vital ./br their continuing care, is not available. If the medical record cannot be produced when needed for patient care, the medical record system is not working properly and confidence in the overall work Qf the medical record service is affected. Selayang Hospital using Electronic Medical Records (EMRs) as their based which are computerized medical information systems that collect, store and display patient information. They are means to create legible and organized recordings and to access clinical information about individual patients. Further, EMRs are intended to replace existing paper based medical records which are already familiar to practitioners at the Selayang Hospital. Patient records have been stored in paper form for centuries and, over this period of time; they have consumed increasing space and notably delayed access to efficient medical care.