Discussion of good clinical practice for public healthcare services in Malaysia

1. GOOD
MEDICAL
PRACTICE
DR LEE OI WAH
KETUA PENOLONG
PENGARAH KANAN
(PERUBATAN)

2. 10 GOLDEN RULES OF GOOD
MEDICAL PRACTICE
1. Practise with Kindness, Ethics and Honesty
2. Upgrade Professional Knowledge and Clinical Skills.
3. Maintain good Patient Records.
4. Maintain good Communication with Patients and
Relatives.
5. Maintain Doctor-Patient Confidentiality.
6. Allow Second Opinion and Referral to Colleagues.
7. Maintain good Working Relationship With Colleagues.
8. Be conscious of Cost of Healthcare.
9. Avoid Publicity, Self-promotion and Abuse of Position.
10. Be a Partner in promoting Global Health.

3. CONTENTS OF PRESENTATION
• The doctor ,the person
• The doctor and the place of practice
• Doctor-patient relationship
• Doctor-patient confidentiality
• Medical records
• Consent
• Chaperone
• Prescription
• Treatment
• Cost of treatment & professional fees
• Second opinion and referral
• Medical certificates
• Advanced directive and End Of Care
• AOR Discharges
• Good Samaritan Law

4. THE DOCTOR, THE PERSON
• The doctor is expected to conduct himself with
professionalism and self-regulation, which in essence implies
that he practices within the established and accepted moral,
legal and ethical norms, and regulates himself to uphold
them.
• The doctor is expected to keep himself abreast of new
developments in medicine generally and in his specialty
specifically, in order to maintain the highest level of
professional care. It is the responsibility of the doctor to utilise
all available components of continuing medical education,
including self-study and distance learning, to achieve these
objectives.

5. THE DOCTOR, THE PERSON
• The physical appearance of the doctor in the way he dresses,
grooms himself, the way in which presents himself in terms of
cleanliness, neatness and personal hygiene, are to the
patient just as important as the doctor's demeanour in terms
of his manners, confidence and general composure .

6. THE DOCTOR & THE PLACE OF PRACTICE
• The CLINIC SIGNBOARD should conform to stipulations and
should be clear and concise.
• The WAITING ROOM should have a calm, soothing and
reassuring ambience. It should be furnished with comfortable
seatings and suitable reading materials and educational posters.
• The CONSULTATION ROOM should be roomy, neat and tidy
with suitably displayed credentials. Clinical equipment should be
in good working order and clean and neatly arranged and
infection control measure is in place.
• The NURSING STAFF must be neatly dressed, courteous and
empathic .They must be efficient and trained to triage patients
according to severity of illness.

7. DOCTOR-PATIENT RELATIONSHIP
The doctor is at all times expected to practise good medicine,
exhibit the norms of good clinical practice and present himself
as follows:
o Be attentive and a good listener.
o Avoid criticising or admonishing the patient.
o Be gentle and concerned when examining the patient. The
physical examination of the patient is to be carried out, without
exception, in the presence of a chaperon.
o Be clear and discreet when discussing the possible
diagnoses,Be cautious and guarded in what should be revealed
at this stage, pending the outcome of the tests.
o Give the relevant options when discussing treatment.

8. DOCTOR-PATIENT RELATIONSHIP
o Be patient and compassionate with the patient during the
course of consultation.
o Avoid criticising colleagues in the presence of patients on
their prior treatment.
o Be gentle when seeking clarifications in the history .
o Avoid being business-like.
o Avoid presenting yourself as the embodiment of noble
perfection .
o Avoid patronising your patients.

9. DOCTOR-PATIENT RELATIONSHIP
o Avoid developing private and personal relationship with your
patient.
o The doctor must take it as his duty to educate and correct a
patient's erroneous or mistaken concepts of medical
treatment and healthcare.
o Never issue prescription or medical sick certificate without
examining the patient first and making relevant notes in the
patient records.
o Never pre-sign sick certificates or prescription pads as these
may be misused by unauthorised persons .

10. BASIC PRINCIPLES OF DOCTOR-PATIENT
CONFIDENTIALITY
o What is interesting to the public VS what is of public health interest.
o Generally ; when a third party seeks medical information, such request
should only be entertained on the explicit written consent of the patient
or the next-of-kin.
o Legal or statutory requirements sometimes override the limits of patient-
doctor confidentiality.
o Doctors who use clinical patient materials in medical publications or at
medical conferences must have at all times avoid revealing personal
details of the patients in the study. Photographs when used should not
reveal identifying facial or physical features
o .
o When discussing patient data at in-house hospital mortality and morbidity
meetings, direct reference to patient's name, identity and personal details
should be avoided

12. CONFIDENTIALITY
The Malaysian Medical Council (MMC) approved the
revised guidelines on Confidentiality at its meeting on 11
October 2011. All practitioners are reminded to comply
with these guidelines which will be used by the MMC in
any disciplinary proceedings.

13. 6 PRINCIPLES OF CONFIDENTIALITY(MMC)
1. Patients have the right to expect that there will be no disclosure
of any personal information, which is obtained during the course of
a practitioner's professional duties, unless they give consent .
2. The professional duty of confidentiality covers not only what a
patient may reveal to the practitioner, but also what the practitioner
may independently conclude or form an opinion about .
3. Confidentiality is an important duty, but it is not absolute. A
practitioner can disclose personal information if:
(a) It is required by law
(b) the patient consents – either implicitly for the sake of their own
care or expressly for other purposes or
(c) it is justified in the public interest

14. 6 PRINCIPLES OF CONFIDENTIALITY(MMC)
4. When disclosing information about a patient, the practitioner shall:
(a) use anonymised or coded information if practicable and if it will
serve the purpose
(b) be satisfied that the patient:
(i) has ready access to information that explains that their
personal information might be disclosed for the sake of
their own care, or for clinical audit, and that they can
object;
(ii) has not objected
(c) get the patient’s expressed consent if identifiable information is
to be disclosed for purposes other than their care or clinical
audit, unless the disclosure is required by law or can be
justified in the public interest
(d) keep disclosures to the minimum necessary, and
(e) keep up to date with, and observe, all relevant legal requirements,
including the common law and data protection legislation.

15. 6 PRINCIPLES OF CONFIDENTIALITY(MMC)
5. When a practitioner is satisfied that information should be
disclosed, the practitioner shall act promptly to disclose all relevant
information.
6. A practitioner shall respect, and help patients to exercise, their
rights to: (a) be informed about how their information will be used,
and (b) have access to, or copies of, their health records

16. PROTECTING INFORMATION
1. A practitioner shall take steps to ensure that the patient’s
confidentiality is maintained regardless of the technology used to
communicate health information . The practitioner should only leave
only names and telephone numbers and NOT confidential
information when using:
• answering machines or voice messaging systems
• email, facsimile or electronic mail.
2. A practitioner should take steps to prevent improper or
unintentional disclosure :
• The practitioner shall not discuss a patient’s information in an
area where the practitioner can be overheard.
• The practitioner should not leave patient’s records, either on
paper or on screen, where they can be seen by other patients,
unauthorized health care staff or the public.
• The practitioner shall take all reasonable steps to ensure that
consultations with patients are private.

17. ELECTRONIC MEDICAL RECORD
• Professional expertise should be used when selecting and
developing systems to record, access and send electronic
data.
• Administrative information, such as names and addresses,
should be accessed separately from clinical information so
that sensitive information is not displayed automatically.
• An information governance policy with protocols and
procedures should be established to ensure that patient
information is documented, maintained and disclosed, in
accordance with all the Principles of Confidentiality .

18. ELECTRONIC MEDICAL RECORD
• The practitioner shall ensure particular cognizance is taken of
the following key principles:
• (a) seek patient’s consent to disclosure of information,
whether or not patients can be identified from the disclosure.
Any exemptions are subject to existing provisions under the
relevant MMC guidelines.
• (b) anonymised data where unidentifiable data will serve the
purpose
• (c) keep disclosures to the minimum necessary.

19. ELECTRONIC MEDICAL RECORD
The measures that should be taken to ensure confidentiality
include :
a. physical security measures to prevent unauthorized access
b. access and authorization processes to ensure only legitimate
users have access to the medical record and that each user
has the appropriate level of access to the medical records
c. the maintenance of audit logs to support the authenticity of
additions to the medical records
d. the protection of any part of an electronic medical record from
being deleted.
e. read-only formats for external documents stored in the
medical
records;

20. ELECTRONIC MEDICAL RECORD
f. adequate protection whenever medical records are disclosed
to health care providers or patients
g. regular back-up of the medical records, preferably daily for
in-patients;
h. adequate virus protection to ensure the medical records are
not modified or destroyed by external factors
i. contingency plans for disaster recovery and denial of service
attacks
j. ensure that no hardware contains any personally identifiable
patient information prior to disposal which must be completed
k. enhanced security e.g. additional encryption or authentication
processes, when networks are more exposed e.g. wireless
devices and remote access, or where the equipment that store
information are on drives that are at risk of loss or theft e.g.
laptops, personal digital assistants

21. DISCLOSURES REQUIRED BY
LAW
2 context include:
i. Disclosure required by statute
ii. Disclosure in court or related to legal proceeding

22. DISCLOSURES REQUIRED BY
STATUTE
o Discosure may be warranted in certain situations :
i. Control of disease esp infectious disease-Inf Disease Act
ii. Profesional regulatory body – MMC, Lembaga Jururawat etc
iii. Investigation of complaints, accidents or deaths – Medicolegal , Mortality
Review
o The practitioner shall satisfy himself or herself that the disclosure sought
is required by law or can be justified in the public interest.
o Whenever practicable, the practitioner shall inform patients about such
disclosures, even if their consent is not required unless that would
undermine the purpose.
o If a patient refuses to consent, or if it is not practicable to seek their
consent, the practitioner shall contact the appropriate regulatory body, to
help him or her decide whether the disclosure can be justified in the public
interest.

23. DISCLOSURES REQUIRED BY
STATUTE
o The practitioner shall disclose only relevant information if
ordered to do so by a judge or presiding officer of a court.
o The practitioner shall not disclose personal information to a
third party such as an advocate or solicitor, police officer or
officer of a court without the patient’s expressed consent,
unless it is required by law or can be justified in the public
interest.

24. DISCLOSURE WITH CONSENT
o A practitioner may release confidential information in
strict accordance with the patient's consent, or the
consent of a person authorized to act on the patient's
behalf. Seeking patient’s consent to disclosure of
information is part of good medical practice.

25. INFORMATION SHARING WITHIN
HEALTHCARE TEAM OR CARE PROVIDERS
o Sharing information within the healthcare team or with others
providing care should be ‘need to know’ basis.
o Where the disclosure of relevant information between health
care professionals is clearly required for treatment to which a
patient has agreed, the patient's expressed consent may not be
required. For example, expressed consent would not be
needed where a practitioner discloses relevant information to
have a referral letter typed, or a practitioner makes relevant
information available when requesting diagnostic
investigations.

26. INFORMATION SHARING WITHIN
HEALTHCARE TEAM OR CARE PROVIDERS
o There will also be circumstances where, because of a
medical emergency, a patient's consent cannot be obtained,
but relevant information must, in the patient's interest, be
transferred betweenhealth care providers.
o All members of a healthcare team have a duty to ensure that
other team members understand and observe confidentiality.
Any one receiving personal information in order to provide or
support care is bound by a legal duty of confidence, whether
or not they have contractual or professional obligations to
protect confidentiality.

27. DISCLOSURE TO 3RD PARTY
o As a general rule, a practitioner shall seek a patient’s
expressed consent before disclosingidentifiable information
for purposes other than the provision of care.
o Where a practitioner or the health care facility in which the
practitioner practises have contractual obligations to third
parties, such as companies, insurance companies or
managed care organizations, the practitioner shall obtain a
patient’s consent before undertaking any examination or
writing a report for the third party.

28. DISCLOSURE IN PATIENT’S BEST
MEDICAL INTEREST
o Disclosure of personal information without consent may be
justified where failure to do so mayexpose the patient to risk of
death or serious harm.
o If it is not practicable to seek consent, the practitioner shall
disclose information promptly to a relevant person or authority.
o Rarely a practitioner may judge that seeking consent for the
disclosure of confidential information may be damaging to the
patient, but that the disclosure would be in the patient's interests.
For example, a practitioner may judge that it would be in a
patient's interests that a close relative should know about the
patient's terminal condition. In such circumstances information
maybe disclosed without consent.

29. DISCLOSURE WHEN PATIENT IS VICTIM
OF NEGLECT OR ABUSE
o If a practitioner believes a patient to be a victim of neglect or
physical, sexual or emotional abuse and that the patient
cannot give or withhold consent to disclosure, the practitioner
shall give information promptly to a relevant person or
statutory agency, where the practitioner believes that the
disclosure is in the patient’s best interests

30. DISCLOSURE IN THE PUBLIC INTEREST
o Personal information may be disclosed in the public interest,
without the patient’s consent, andin exceptional cases where
patients have withheld consent, where the benefits to an
individual or to society of the disclosure outweigh the public and
the patient’s interest in keeping the information confidential.
o Example :
(a) the patients are not competent to give consent
(b) the records are of such age and/or number that reasonable
efforts to trace patients are unlikelyto be successful
(c) the patient has been, or may be violent; or obtaining
consent would undermine the purpose of the disclosure
(e.g. disclosures in relation to crime)
(d) action must be taken quickly (for example in the detection or
control of outbreaks of somecommunicable diseases) and
there is insufficient time to contact patients.

31. DISCLOSURE IN THE PUBLIC INTEREST
o In cases where there is a serious risk to the patient or others,
disclosures may be justified even where patients have been
asked to agree to a disclosure, but have withheld consent.
The practitioner shall document in the patient’s record any
steps taken to seek or obtain consent and the reasons for
disclosing information without consent.
o Ultimately, the “public interest” can be determined only by the
courts.

32. DISCLOSURE FOR MEDICAL TEAHING,
CLINICAL AUDIT & OTHER 2◦ REASONS
o For many secondary uses, it will be sufficient and
practicable to disclose only anonymised or coded
information. When identifiable information is needed, or it is
not practicable to remove identifiable information, it will often
be perfectly practicable to get the patient’s expressed
consent.
o Where teaching, research or audit is to be undertaken by
the team which provided care, or those working to support
them, the practitioner may disclose identifiable information,
provided he or she is satisfied that patients have been
informed that their data may be disclosed, and their right to
thedisclosure and have not objected.

33. DISCLOSURE FOR MEDICAL TEAHING,
CLINICAL AUDIT & OTHER 2◦ REASONS
o Where medical research and/or audit are to be undertaken, the
information shall be anonymised wherever that is practicable.
o When considering whether the public interest in disclosures for
secondary uses outweighs the patient’s and the public interest in
keeping the information confidential, the practitioner shall
consider:
(a) the nature of the information to be disclosed
(b) what use will be made of the information
(c) how many people will have access to the information
(d) the confidentiality and security arrangements in place to
protect the information from further disclosure
(e) the advice of an expert, who is not directly connected with
the
use for which disclosure is beingconsidered, and
(f) the potential for distress or harm to patients.

34. DISCLOSURE FOR MEDICAL TEAHING,
CLINICAL AUDIT & OTHER 2◦ REASONS
o The practitioner shall only disclose identifiable information for
research if that research is approved by a Research Ethics
Committee. The practitioner shall alert Research Ethics
Committees to disclosures of identifiable information without
consent when applying for approval for researchprojects.

35. DISCLOSURE OF PATIENT WHO LACK
CAPACITY TO CONSENT
o When making decisions about whether to disclose
information about a patient who lackscapacity, the practitioner
shall: (a) makethe care of the patient the first concern (b)
respect the patient’s dignity and privacy, and (c) support and
encourage the patient to be involved, as far as they want and
are able, in decisionsabout disclosure of their personal
information.

36. DISCLOSURE OF PATIENT WHO LACK
CAPACITY TO CONSENT
o Factors to consider before making decision to disclose:
(a) whether the patient's lack of capacity is permanent or
temporary and, if temporary, whether thedecision to disclose
could reasonably wait until they regain capacity
(b) any evidence of the patient's previously expressed
preferences
(c) the views of anyone the patient asks the practitioner to
consult, or who has legal authority to make a decision on their
behalf, or has been appointed to represent them
(d) the views of people close to the patient on the patient’s
preferences, feelings, beliefs and values, and whether they consider
the proposed disclosure to be in the patient's best interests,
(e) what the practitioner and the rest of the healthcare team know about
the patient's wishes,feelings, beliefs and values.

37. DISCLOSURE OF PATIENT WHO LACK
CAPACITY TO CONSENT
o If a patient who lacks capacity asks a practitioner not to disclose
personal information about their condition or treatment, the
practitioner shall try to persuade them to allow an relevant
person to be involved in the consultation. The practitioner shall
document in the patient’s record the discussions and the reasons
for deciding to disclose theinformation.
o The practitioner may need to share personal information with a
patient’s relatives, friends or carers to enable the practitioner to
assess the patient’s best interests. But that does not mean they
have a general right of access to the patient’s records or to have
irrelevant information about, for example, the patient’s past
healthcare

38. DISCLOSURE IN PAEDIATRIC PATIENT
o If such patients ask the practitioner not to disclose information
about their condition or treatment to a third party, the
practitioner shall try to persuade them to allow a relevant
person to be involved in the consultation. If they refuse
and the practitioner is convinced that it is essential, in their
medical interests, the practitioner may disclose relevant
information to a relevant person or authority. In such
cases the practitioner shall inform the patient before
disclosing any information, and where appropriate, seek and
carefully consider the views of an advocate or carer. The
practitioner shall document in the patient’s record the
discussions with the patient and the reasons for deciding to
disclose information.

39. INFORMATION SHARING WITH PATIENT’S
SPOUSE, PARTNERS, RELATIVES OR
FRIENDS
o The practitioner shall establish with the patient what
information they want to share,who with, and in what
circumstances.
o This will be particularly important if the patient has fluctuating
or diminished capacity or is likely to lose capacity, even
temporarily.
o The practitioner might need to share with a patient,
information which was received from others, for example, if it
has influenced thepractitioner’s assessment and treatment of
the patient.

40. DISCLOSURE OF GENETIC & OTHER
SHARED INFORMATION
o The diagnosis of an illness in the patient might, for example, point to
the certainty or likelihood of the same illness in a blood relative.
o Most patients will readily share information about their own health
with their children and other relatives, particularly if they are advised
that it might help those relatives to:
(a) get prophylaxis or other preventative treatments or
interventions
(b) make use of increased surveillance or other investigations, or
(c) prepare for potential health problems.
o If a patient refuses consent to disclosure, the practitioner will need to
balance the practitioner’s duty to make the care of the patient the
first concern against the practitioner’s duty to help protect the other
person from serious harm.

41. DISCLOSURE OF GENETIC & OTHER
SHARED INFORMATION
o The practitioner shall be guided by the following:
(a) The use or disclosure of genetic information without consent may proceed only
when the practitioner has a reasonable belief that this is necessary to lessen or
prevent a serious threat to the life, health or safety of a genetic relative.
(b) Reasonable steps shall be taken to obtain the consent of the patient or a relevant
person to use or disclose genetic information.
(c) Prior to any decision concerning the use or disclosure, the practitioner shall
discuss the case with practitioners with the appropriate expertise to assess fully
the specific situation.
(d) Where practicable, the patient’s identity shall not be apparent or readily
identifiable in the course of inter-professional communication.
(e) Disclosure of genetic information without consent shall generally be limited to
relatives no further removed than third degree relatives.
(f) All stages of the process shall be fully documented including how the decision to
use or disclose without consent was made.

42. DISCLOSURE AFTER A PATIENT’S DEATH
o The practitioner still has an obligation to keep personal information
confidential after a patient dies.
o The extent to which confidential information may be disclosed after a
patient’s death will depend on the circumstances:
(a) whether the person requesting the information has locus standi;
(b) whether the disclosure of information may cause distress to, or be
of benefit to, the patient’s partner or family;
(c) whether disclosure of information about the patient will in effect
disclose information about the patient’s family or other people;
(d) whether the information is already public knowledge or can be
anonymised;
(e) the purpose of the disclosure.

43. DISCLOSURE AFTER A PATIENT’S DEATH
o There are circumstances in which a practitioner shall disclose
relevant information about a patient who has died, for example:
(a) to help a coroner or other similar officer in an inquest or fatal
accident inquiry
(b) when disclosure is required by law or is justified in the public
interest, such as for education or research
(c) for National Confidential Inquiries or for clinical audit
(d) on death certificates, which the practitioner shall complete
honestly and fully
(e) for public health surveillance, in which case the information
should be anonymised or coded, unless that would defeat the
purpose
(f) when a parent asks for information about the circumstances and
causes of a child’s death.

44. MEDIA INQUIRIES ABOUT PATIENT
o Before releasing any information, the practitioner shall:
a) Remember that information which the practitioner has learnt
in a professional capacity shall be regarded as confidential
whether or not the information is also in the public domain.
(b) Expressed consent shall be obtained from the patient before
discussing matters relating to their care, with the media,
whether or not the patient's name or other identifying
information is to be revealed. Expressed consent shall be
obtained if patient will be identified from the details disclosed.
(c) Remember that a patient can be identified from information
other than name or addresses. Details which in combination
may reveal a patient’s identity include their condition or
disease, age, occupation, the area where they live, medical
history or the family.
(d) Always consider and act in accordance with the best medica
interests of patients when responding to invitations to speak to
the media about patients.

46. MEDICAL RECORDS

47. INTRODUCTION
o A medical record is documented information about the
health of an identifiable individual recorded by a practitioner
or other healthcare professional, either personally or at his
or her instructions.
o It should contain sufficient information to identify the
patient, support the diagnosis based on history, physical
examination and investigations, justify the professional
management given, record the course and results thereof,
and ensure the continuity of care provided by practitioners
and other healthcare workers to that particular patient.
o The concept is that medical records were documents which
belonged to the physician and were therefore retained by
him in his place of practice.

48. INTRODUCTION
o The medical records were considered “confidential”
documents in testimony to good medical practice and the
information therein contained considered “private” in
observance of ethical doctor-patient relationship.
o It is imperative that the doctor is at all times aware that the
Medical Record is a valuable document in patient care which
may be read or disclosed subsequently, and therefore must
be complete, objective and comprehensive.

49. CONTENTS OF PATIENT’S MEDICAL RECORD
o Doctor’s clinical notes
o Recording of Discussion with patient /next of kin regards disease/
management (with witness) / Possible use of tape recording
o Referral Notes to other specialist(s) for consultation / comanagement
o Laboratory & Histopathological reports
o Imaging records and reports
o Clinical Photographs
o Drug Prescriptions
o Nurses’ Reports
o Consent Forms, At-Own-Risk Discharge Forms
o Operation Notes/Anaesthetic Notes
o Video Recordings
o Printouts from monitoring equipment (e.g. ECG, EEG, CTG)
o Letters to and from other health professionals
o Computerized/electronic records
o Recordings of telephone consultations/instructions relevant to the care of
the patient.

50. INTEGRATED CASE NOTES
o The medical practitioner, the nursing staff, the physiotherapist and
occupational therapist, dietician and any other person involved in the
management of the patient will all make contemporaneous entries on
the same Continuation Sheet in the Medical Records.
o This would enable each and every member of the management team
(Doctor, Nurse, Physiotherapist, Dietician, etc) to keep direct track of
the daily management procedures
of a patient, without having to refer to other records in the
folder.
o The entry in the Continuation Sheet should be precise and legible
and record the Date, Time and the Procedure or Treatment, in
chronological sequence, and should be signed by the person making
the entry.
o The name of the person should be clearly written below the
signature, or the name rubber-stamped, so that the person making
the entry can be traced later without difficulty, if such need arises.

51. USE OF ABBREVIATIONS OR SHORT FORMS
o Abbreviations and short forms should generally be avoided
when making entries in the Clinical Notes and Continuation
Sheets.
o When used at all, these abbreviations and short forms should
be those traditionally accepted and recognised by healthcare
personnel.
o Institutions and healthcare facilities may provide a list of such
traditionally accepted and recognised abbreviations for use
and reference by their staff.

52. PROPER ENTRIES
o It is imperative that the practitioner, nursing staff or any ancillary staff
should strictly avoid entering irrelevant, disparaging, derogatory and
offensive personal remarks about the patient, or other colleagues and
healthcare workers, in the patient’s Clinical Notes.
o Practitioners and nursing and ancillary staff should avoid leaving blank
spaces in between entries in the Continuation Sheet so that no person
may be able to make late or retrospective notes in such space.
o Erasure or “blacking out” of entries already made in the Continuation
Sheet should be avoided. If there are reasons for some corrections, the
erroneous statement should be neatly crossed out, but still be readable.
The correction should then be entered in space available next to the
deleted statement, and signed clearly by the person making the
correction.

53. PATIENT’S RIGHTS TO MEDICAL RECORDS
o It is generally accepted that the patient should:
• have access to records containing information about his/her
medical condition for legitimate purpose and in good faith;
• know what personal information is recorded,
• expect the records are accurate, and
• know who has access to his/her personal information.
o Patient may be permitted to inform the practitioner of any factual
errors in the personal patient information.
o However , patient should not seek to change any entries
made by the practitioner in the course of consultation, diagnosis
and management as these are made by the practitioner based
on his clinical judgement.

54. LEGAL STATUS OF MEDICAL RECORDS &
MEDICAL REPORTS
o Medical Records, while not strictly classified legal documents,
may be considered legally supportive documents in a court
hearing.

55. STATUS OF MEDICAL RECORDS
WITHIN HEALTHCARE FACILITIES
o Medical Records are to be classified “Confidential” for
administrative purposes within a healthcare facility.
o It is acceptable to label the Medical Record on the cover “Not
to be handled by the Patient”.

56. HANDLING OF MEDICAL RECORDS BY
NURSING & ANCILLARY STAFFS
o These staff must appreciate, and be impressed upon, the
confidential nature of the Medical Records, and must at all
times ensure that the contents and information are closely
guarded and protected.
o The ultimate responsibility in this context rests with the
Person in Charge (Chief Executive Officer / or Director) of the
healthcare facility.

57. SECURITY OF MEDICAL RECORDS
o The security and safekeeping of Medical Records is the
responsibility of the Person in Charge, Chief Executive Officer
(CEO) or the Medical Director of the healthcare facility or
service.
o Medical Records must be stored in safe and secure rooms at
all times when not in use.
o Medical records must be easily accessible and retrievable
when required and returned in a complete form after use.
o As a general rule, Medical Records must not be taken out of
the healthcare facility.

58. SECURITY OF MEDICAL RECORDS
o When medical record is required by a court order, a copy of
the records shall be retained by the private healthcare facility
or hospital and the original records shall be returned to the
private healthcare facility or hospital at the end of the
proceedings for which the records were directed to be
procured.
o Medical Records are often required to accompany an in-
patient to the Imaging Department, Rehabilitation
Department, Operation Theatre, etc, within the healthcare
facility or service. Their safekeeping in transit and in the
aforementioned departments must be ensured by the Person
in Charge(PIC).

59. OWNERSHIP OF MEDICAL RECORDS
o A patient’s medical record is the property of the medical
practitioner and the healthcare facility and services, who hold
all rights associated with ownership.
o However , the practitioner and healthcare facility should still
obtain consent from the patient or next of kin before any
release of information from the medical records to any third
person.
o Medical records are also the intellectual property of the
medical practitioner who has written them, and also belong
morally and ethically to the practitioner and the patient.
o The results of investigations (blood tests, tests on secretions,
imaging and scans) belong to the patient, and these may be
released to him/her when requested.

60. OWNERSHIP OF MEDICAL RECORDS
o Unless imaging records (e.g. X-ray, ultrasound) have to be
practitioner or the healthcare facility or service for medico-
legal reasons, or for continuing patient care, patients should
generally be given their X-rays or copies of the X-rays for
their retention.
o Photo-copies of Laboratory Test Results may be given to the
patient if requested.
o Specimens obtained for histopathological examination and
slides made of such specimens should generally be retained
by the practitioner or healthcare facility or service, though
copies of the reports may be given to the patient on request.

61. TRANSFER OF PATIENT TO ANOTHER
HOSPITAL
o When a patient is transferred to a second healthcare facility
or service for whatever reason, the primary practitioner is
expected to provide a full Clinical Summary without undue
delay and with full knowledge of his/her previous treatment.
o The primary practitioner is to provide photo-copies, or full
details, of all relevant results of investigations, and copies of
all important recordings (ECG, intensive care monitoring) and
radiographs, Magnetic Resonance Imaging, Computer
Tomogram Scans, Ultrasounds, etc.
o The original whole Medical Record shall be retained
physically with the primary medical practitioner and should be
accessible to the referred second facility or service if needed
for continuing management of the patient.

62. ACCESS TO MEDICAL RECORDS
o The patient may be entitled to access Medical records as part of the
contract between him/her and the medical practitioner, for various
purposes, ranging from need to seek second opinion, to seek further
treatment elsewhere, or for litigation. This privilege is also extended with
the patient’s consent to the patient’s appointed agents.
o Medical practitioners and persons in charge of healthcare facilities and
services are generally expected to cooperate and release all parts of the
medical records, or certified true copies of the records, when so
requested by the patient.
o If the patient’s or agents’ request for access is refused after all other
avenues have been explored, a patient may then resort to civil action.
Legal proceedings are commenced by issuing a writ to permit the
process of ‘order of discovery’ to proceed after which documents may be
subpoenaed.

63. ACCESS TO MEDICAL RECORDS
o The patient, and/or his appointed agent/officer, on written
request, is entitled to a written Report on the care given to the
patient as recorded in the Medical Record, and relevant
copies of their Medical Records.

64. DISCLOSURE TO 3RD PARTY & MANAGED
CARE ORGANIZATIONS (MCO)
o Release of information from the Medical Records to Third
Party Payers and Managed Care Organisations, and through
them to the employers, should only be made with the
informed consent of the employee/patient.
o Informed consent for disclosure must be on a case-by -case
basis and should be obtained by the practitioner personally
from the patient.

65. DENIAL OF DISCLOSURE BY
PRACTITIONER
o The practitioner may deny disclosure of the contents of the
Medical Record if :
a. if in his considered opinion, the contents if released may be
detrimental or disparaging to the patient, or any other
individual.
b. liable to cause serious harm to the patient’s mental or
physical health or endanger his life
c. if the patient is deceased
d. if there is no written consent from the patient, or his legal
next-of-kin or guardian

66. MEDICAL REPORT

67. INTRODUCTION
o Medical Reports are documents prepared by a practitioner on
a patient based on Medical Records. Opinion by an Expert
may also be part of a Medical Report.
o Practitioners are obliged to provide comprehensive medical
reports when requested by patients or by the next of kin (in
the case of children or minors ) or by the employer with the
patient’s specific consent.

68. CONTENTS OF A MEDICAL REPORT
o Patient identification data
o Dates and time of admission or treatment,
o Brief history
o Significant examination findings
o Results of relevant investigations
o Diagnosis
o Treatment
o Management plan

69. CONTENTS OF A MEDICAL REPORT
o The Medical Report should only contain facts.
o When an opinion is requested, with regards employment,
disability, further management, etc., this should be separated
from the facts of the Report and identified as Opinion or
Recommendation.
o Certified true copies of results of relevant investigations, or
records, may be included as a part of the Medical Report.

70. LEGAL STATUS OF MEDICAL REPORT
o Medical Reports, like Medical Records, can be demanded
and produced as legally supportive documents.
o The Court has the right to call the practitioner who generated
the Medical Report to appear before the presiding judge or
magistrate to explain or clarify the contents of such Report as
may be required.
o Where the practitioner anticipates a medico-legal problem
arising out of a Medical Report, he may be advised to obtain
the opinion of legal counsel and/or the person in charge/
CEO/Medical Director of the healthcare facility.

71. REFUSAL TO PROVIDE MEDICAL REPORT
o It is unethical for a practitioner to refuse to provide a Medical
Report and the patient has every right to complain to the
Medical Council of any such refusal or undue delay.
o The withholding of Medical Reports because of failure of the
patient to settle professional and healthcare facility and
services fees and bills is unethical.

72. FEES FOR MEDICAL REPORT
o A reasonable quantum of fees may be charged for a Medical
Report and this may vary according to the details and length
of the report.
o The amount of the fees charged must be communicated to
the patient or the authorized agent requesting the report for
their agreement to pay.
o It is reasonable to obtain the fees in advance.

73. MEDICAL REPORT WHEN PRACTITIONER IS
DECEASED
o The person in charge(PIC) of the healthcare facility or service where the
patient had been treated must obtain permission from the next of kin or
legal representative of the deceased practitioner for release of
information.
o The PIC must seek a practitioner of the same specialty, preferably but
not necessarily from the same healthcare facility or service, and such a
practitioner being acceptable to the patient and the deceased
practitioner’s next of kin or legal representative, to write the Medical
report.
o The practitioner willing to write the medical report must then write the
report factually as recorded in the Medical Record of the patient without
any interpretations or opinions on statements or findings recorded in the
patient’s notes by the deceased practitioner.

74. 2ND OPINION
o When Second Opinion is sought from another practitioner at
the request of the patient or next of kin, the primary
practitioner should provide a comprehensive summary with
relevant details of investigations and management of the
patient. The Medical Record, if requested for perusal by the
practitioner giving the second opinion, should also be made
available.
o The doctor/specialist giving the report as a second opinion
may charge a reasonable quantum of fees, which may be
obtained in advance.

75. EXPERT OPINION
o When a practitioner is required to give an Expert Opinion, the
entire Medical Record should be made available for the
doctor to study or peruse in the course of preparing his expert
opinion.
o A practitioner involved in the management of the patient or
working in the same healthcare facility or Ministry as the
doctor in the inquiry, should not appear as expert witness in
such inquiry.
o A list, or a pool, of Expert Medical Witnesses, willing to give
expert opinion in legal proceedings, may be held by specialist
professional organisations and any request for an expert
witness from legal councel may then be appropriately
processed by such specialist organisations.

77. DEFINITION
o Consent is a voluntary agreement with an action proposed by
another. Consent is an act of reason; the person giving consent
must be of sufficient mental capacity and be in possession of all
essential information in order to give valid consent.
o Obtaining a patient’s consent is an important component of good
medical practice, and also carries specific legal requirements to
do so. Except in an emergency where the need to save life is of
paramount importance, the consent of the patient must be
obtained before the proposed procedure, examination, surgery, or
treatment - is undertaken.

78. NECESITY TO INFORM PATIENTS
ABOUT MATERIAL RISK
o A medical practitioner is obliged to disclose information to the
patient and to warn the patient of material risks before taking
consent.
o The medical practitioner must inform the patient, in a manner
that the patient can understand, about the condition,
investigation options, treatment options, benefits, all material
risks, possible adverse effects or complications, the residual
effects, if any, and the likely result if treatment is not undertaken.
o It is recommended that practitioners provide additional
information on risks and adverse effects of any procedure in a
written explanatory document which the patient (or next-of-kin or
legal guardian) can read, request further explanation where
necessary, understand and append a signature to that effect.

79. TYPES OF CONSENT
o Implied consent
o Expressed consent
o Informed consent
o Valid consent
o Verbal consent
o Non-verbal consent
o Written consent

80. IMPLIED CONSENT
o Implied consent is a form of consent which is not expressly
granted by a person, but rather inferred from a person's
actions and the facts and circumstances of a particular
situation (or, in some cases, by a person's silence or
inaction).

81. EXPRESSED CONSENT
o Expressed consent may be in oral, nonverbal or written form
and is clearly and unmistakably stated.

82. INFORMED CONSENT
o Informed consent can be said to have been given based upon a
clear appreciation and understanding of the facts, implications,
and future consequences of an action.
o In order to give informed consent, the person concerned must
have adequate reasoning capacity and be in possession of all
relevant facts at the time consent is given.
o Informed consent is a medico legal requirement or procedure to
ensure that a patient knows all of the risks and costs involved in
a treatment.
o The elements of informed consents include informing the patient
of the nature of the proposed procedure, surgery, treatment or
examination, possible alternative treatments, and the potential
risks and benefits of the treatment.

83. VALID CONSENT
o Valid consent can be defined as the voluntary agreement by
an individual to a proposed procedure, given after
appropriate and reliable information about the procedure,
including the potential risks and benefits, has been
conveyed to the individual.

84. PRE-REQUISITE FOR A VALID CONSENT
i. It must be given by a person with legal capacity, and of
sufficient intellectual capacity to understand the implications
of undergoing the proposed procedure.
ii. It must be taken in a language which the person understands.
iii. It must be given freely and voluntarily, and not coerced or
induced by fraud or deceit.
iv. It must cover the procedure to be undertaken.
v. The person must have an awareness and understanding of the
proposed procedure and its known or potential risks.

85. PRE-REQUISITE FOR A VALID CONSENT
vi. The person must be given alternate options to the proposed
treatment or procedure.
vii. The person must have sufficient opportunity to seek further
details or explanations about the proposed treatment or
procedure.
vi. There must be a witness/interpreter, who may be another
registered medical practitioner or a nurse, who is not directly
involved in the management of the patient nor related to the
patient or the medical practitioner, or any such person who can
speak the language of the patient, to attest to the process
during taking of the consent.

86. VERBAL CONSENT
o Verbal consent is given by using verbal communication, and
may be open to debate and as far as possible, should be
avoided.

87. NON-VERBAL CONSENT
o Non-verbal consent is given by using non-verbal
communication, like nodding acquiescence or extending the
arm for a procedure, which are also open to debate. In such
instances, it may be prudent to make an entry in the patient’s
notes that such consent was given.

88. WRITTEN CONSENT
o The Private Healthcare Facilities and Services (Private
Hospitals and Other Private Healthcare Facilities)
Regulations 2006 states in Part VIII Consent under section 47
(3) “Consent obtained or caused to be obtained under this
regulation shall be in writing.”

89. CONSENT IN EMERGENCY SITUATION
o A medical emergency is defined as an injury or illness that is
acute and poses an immediate risk to a person's life or long
term health.
o A consensus of the primary surgeon/physician (who is
managing the patient) and a second registered practitioner is
obtained and the primary surgeon/physician signs a
statement with the consent form stating that the delay is likely
to endanger the life of the patient. The second registered
medical practitioner must co-sign the consent form.

90. CONSENT IN ‘MINOR’ PATIENT
o The Laws of Malaysia Act 21: Age of Maturity Act 1971
states under Age of majority: “The minority of all males and
females shall cease and determine within Malaysia at the age
of eighteen years and every such male and female attaining
that age shall be of the age of majority” .
o For the purposes of the Regulations, a patient who is
unmarried and below 18 years of age does not have the
capacity to give valid consent to any medical procedure or
surgery.
o If a minor presents with an adult other than a parent, the
attending medical practitioner should attempt to ascertain the
adult's relationship to the child and whether the adult is the
child's guardian.

91. CONSENT IN ‘MINOR’ PATIENT
o Where the patient is an “infant” as defined under the
Guardianship of Infants Act 1961, it would be prudent for the
medical practitioner to consult or obtain the consent of the
infant’s legal guardian.
o The Law Reform (Marriage & Divorce) Act 1976 makes it
clear that each parent has full responsibility for each of
his/her children who is under 18 years of age. Parental
responsibility is not affected by changes to relationships (i.e.
if the parents separate). Each parent has the responsibility for
his/her child's welfare, unless there is an agreement or a
Court has made an order to the contrary.

92. PATIENTS INCAPABLE OF OR IMPAIRED
WITH DECISION MAKING ABILITY
o Impairments to reasoning and judgment which may make it
impossible for someone to give informed or valid consent
include such factors as basic intellectual or emotional
immaturity, high levels of stress such as Post Traumatic
Stress Disorder (PTSD) or as severe mental retardation,
severe mental illness, intoxication, severe sleep deprivation,
Alzheimer's disease, or being in a coma.
o In an emergency situation to save life, the procedure as
outlined for emergency treatment or management should be
followed.
o When there is a relative, next-of-kin or legal guardian is
available, and the relationship well established or confirmed,
the consent may be obtained from such a person if an
elective or non-emergency operation is necessary

93. MENTAL HEALTH ACT
o Under the Mental Health Act 2001, consent is generally not required
for conventional treatment apart from surgery, electroconvulsive
therapy or clinical trials for patients with mental disorder as defined
by the said Act.
o In instances where consent is required it must first be obtained from:
i. The patient himself if he is capable of giving consent as
assessed by a psychiatrist; or
ii. If the patient is incapable of giving consent, from his guardian
in the case of a minor or a relative in the case of an adult,
“guardian” and “relative” as defined in the Mental Health Act;
iii. Two psychiatrists, one of whom shall be the primary or
attending psychiatrist, if the guardian or relative of the patient
is unavailable or untraceable and when the patient himself is
incapable of giving consent.

94. PRE-REQUISITE FOR A MEDICAL
PRACTITIONER TAKING CONSENT
a. The practitioner and the patient must have met or know
each other, through previous consultation or contact, in
the context of doctor-patient professional relationship.
b. The practitioner who is planning to operate or do an invasive
procedure on a patient must establish personal contact with
the patient, in other words the two must meet before the
intended procedure.
c. The doctor must explain to the patient the nature of the
procedure and its objective, and alternative procedures.
d. The doctor must explain possible risks and complications,
which may delay or affect the result of the procedure, as well
as influence the duration of stay in the ward or in intensive
care.

95. RESPONSIBILITY OF THE MEDICAL
PRACTITIONER TAKING CONSENT
o It is generally required that only fully registered medical
practitioners may take consent for a procedure, examination,
surgery, or treatment - from a patient, and also perform the
procedure, examination surgery, or treatment- for which that
consent has been taken.
o The primary responsibility and vicarious liability in the event of
complaints rests on the practitioner who has taken the consent
and who additionally has himself performed the procedure,
surgery, treatment or examination.
o In the event of the practitioner taking the consent and the
practitioner performing the procedure, being two different
registered medical practitioners, the final responsibility and
liability will rest on the practitioner who performs the procedure.

96. CONTENT OF A STANDARD CONSENT FORM
o A standard consent form should contain:
a. Patient identification data: Name, IC Number, Address, gender
b. Name of procedure/surgery to be performed in full
c. Type of anaesthesia
d. Name(s) of registered medical practitioner(s) performing the procedure/
surgery.
e. Permission to proceed with any additional procedure that may become
necessary during the surgery and related to the procedure for which the
original consent had been obtained.
f. A statement to the effect that the person who is performing the procedure
has explained to the patient (or next-of-kin) the nature of the procedure
and the potential material risks.
g. A statement to indicate that the Patient has received and read additional
Explanatory Notes, if so provided by the practitioner.
h. Signature of Patient/next-of-kin (relationship) and IC Number and date
i. Signature of Practitioner and name stamp, and date
j. Signature & name of Witness (to the signing of the form) and date.

97. PREPARED MATERIAL WITH INFORMATION
ABOUT TREATMENT
o Prepared material such as brochures or standard forms (with
translations where relevant) with information about a procedure,
surgery, treatment or examination may be useful if given to the
patient as a means of stimulating discussion and for guiding the
medical practitioner when informing the patient about a proposed
procedure, surgery or treatment.
o However pre-prepared material should not be used as a
substitute for informing or making sure that a patient understands
the nature of, and risks involved in, the procedure, surgery or
treatment, as the provision of such material per se will not
necessarily discharge the medical practitioner from his legal duty.
o The medical practitioner must ensure that any pre-prepared
material given to the patient is current, accurate and relevant to
the patient .

98. FAXED OR PHOTOCOPY OF CONSENT FORM
o It is necessary for the patient, or next-of-kin or legal guardian
to be physically present before a registered medical
practitioner for purposes of giving consent for a procedure,
surgery, treatment or examination.
o For the above specific reasons, faxed or photocopied consent
form is not acceptable.

99. PERIOD OF VALIDITY OF CONSENT
o It is generally believed that for an acceptable standard of
care, the consent for an invasive procedure has to be taken
within a reasonable period of not more than 7 days before
the procedure.
o If during this period there is a change in the circumstances or
condition of the patient requiring a review of the procedure
initially planned, for which consent had been taken, then it is
incumbent on the practitioner to obtain a fresh consent.
o In instance when a patient from whom consent had been
taken for a particular procedure, and the procedure is delayed
or postponed, including and especially when an in-patient is
discharged home, a new consent has to be taken before
undertaking the procedure, examination, surgery, or
treatment .

100. PERIOD OF VALIDITY OF CONSENT
o It sometimes is the practice of convenience in many
healthcare facilities that consent is taken when the patient is
being seen in the clinic by the practitioner, and while
scheduling the procedure or treatment, which may be in a
week’s time or later. A new consent must be taken if the
delay has been more than 30 days since the last consent.

101. CONSENT IN CHRONIC CONDITIONS
REQUIRING PERIODIC TREATMENT
o Good standard of care requires that consent has to be
contemporaneous (specific in time) and procedure for any
invasive treatment.

102. CONSENT FOR PHOTOGRAPH & AUDIO-
VISUAL RECORDING
o Prior consent must be obtained if the practitioner is planning
to take clinical photographs or to make audio-visual
recordings before, during or after an invasive procedure.
o Such photographs and audio-visual recordings rightfully
belong to the patient and if to be retained by the practitioner,
further consent must be obtained.
o If such photographs or audio-visual recordings are requested
by the patient to be taken away, it is necessary to keep
copies of such material in the patient’s records, for future
requirements, like medical reports .

103. CONSENT ON ADMISSION & RELEASE OF
INFORMATION
o Based on the principles that consent must be specific for a
procedure, “blanket” consent is not allowed.
o Consent obtained should be specific to the needs ie :
a. Release of information to 3rd party or MCO –only details of
diagnosis and management
b. Release of results or pre-employment medical report

104. CONSENT FOR INVESTIGATION OF HIV
o Because of the special implications to persons who may test
positive for HIV, and the need for counselling and further
management, specific consent has to be taken before the
tests are carried out.

105. CONSENT FOR KEEPING TISSUES & ORGANS
REMOVED AT SURGERY FOR TEACHING
PURPOSE
o The surgeon may seek the consent of the patient or next-of-kin to
retain the specimens for medical education or research purposes,
but without having to reveal the identity of the patient.
o Section 2 of the Human Tissues Act 1974:
Where the deceased during his lifetime has, either in writing or
verbally in the presence of two or more witnesses during his last
illness, expressed a request that his body or a specified tissue in
his body be used after his death for therapeutic purposes, or for
purposes of medical education or research, the person lawfully in
possession of his body after his death may authorize the use of
the deceased’s body or removal of the organs, unless he has
reason to believe that the request was withdrawn.

106. CONSENT FOR STERILIZATION,
HYSTERECTOMY & ORCHIDECTOMY
o Consent for above procedures in a woman or man should be
given by the patient concerned. Any discussion between the
spouses in this respect does not and should not deny the
rights of the patient concerned in making the final decision
and giving consent.

107. REFUSAL TO GIVE CONSENT FOR
TREATMENT
o Generally, every individual is entitled to refuse medical
treatment. A legally competent person has a right to choose
what occurs with respect to his or her own person.
o The refusal of treatment by a patient should also be recorded
in detail and in writing in the medical record or the medical
practitioner’s case notes, and where possible, signed and
dated by the patient.

109. INTRODUCTION
o A doctor must always examine a patient, whether female or
male, or a child, with a chaperon being physically present in
the consultation room, with visual and aural contact
throughout the proceedings.
o Physical examination and therapies, particularly intimate
ones, demand psychological and practical comfort for the
patient as well as protection for the doctor from allegations
of impropriety.

110. DEFINITION
o One who accompanies a physician during physical
examination of a patient with opposite gender.

111. WHEN TO USE CHAPERONE ?
o Depend on the nature of the examination or procedures
o Circumstances when or where is the examination or
procedures.
o A relative or friend of the patient is not a reliable chaperone,
appreciate the nature of the physical examination performed
by the doctor and may even testify against the doctor in the
event of allegations of misconduct or physical abuse –
‘Hostile Witness’

112. PRE-REQUISITE OF A CHAPERONE
o A chaperone should preferably be a trained member of a
professional clinical team :
a. Know the purpose of chaperone
b. Know the purpose of examination
c. Fit-mentally , physically and knowledgeable.
o The person should be able to perform a dual function of being
a chaperone and also to assist the practitioner.
o In the event a patient declined having a chaperone, the
practitioner should document in the case notes or put in
Incident Reporting.

114. GOOD CLINICAL PRACTICE IN
PRESCRIBING
o Before prescribing medication for a patient, it is good medical
practice to find out if the patient has had any adverse reactions
to medications previously taken, any allergies, asthma, skin
diseases and whether patient is treatment for any other illnesses.
o Avoid duplicate medication.
o It is good medical practice to inform the patient the purpose of
the medications, and potential adverse reactions that may
sometimes arise.
o The name of the medicine, preferably both the generic and
trade, should be clearly labeled.

115. GOOD CLINICAL PRACTICE IN
PRESCRIBING
o Some patients carry little pocket notebooks in which they keep a
record of medicines they are taking regularly, and the doctor
should enter new prescriptions therein.
o Medications should be prescribed in most circumstances, for an
appropriate convenient duration, particularly for diseases that
may need close periodic monitoring.
o Dispensing of medication in the clinic should be on the direction
and supervision of the doctor in the absence of a qualified
dispenser.
o Patients should be warned against self medication or purchasing
controlled medication without prescription.

117. GOOD CLINICAL PRACTICE IN
TREATMENT
o The patient should not be made to feel that a particular
treatment is being forced upon him, especially elective
surgical procedures which are invasive.
o In elective surgery, it is good practice to offer options
regarding dates and convenience, so that the patient has time
to sort out personal and work-related matters.

119. GOOD CLINICAL PRACTICE REGARDING
TREATMENT FEES
o It is good medical practice for the doctor to make available to the
patient an estimate of his professional charges and the hospital
charges prior to commencing treatment.
o In the case of emergencies, medical ethics and humane
considerations dictate that doctors render emergency or life
saving treatment to patients irrespective of their ability to pay.
Subsequent management of the patient will depend on the
ability of the patient to meet the charges.
o In private hospital practice, when the expenses begin to exceed
initial estimates for patients who unexpectedly require intensive
or long-term the attention of the patient or the next-of-kin. If
there is inability to meet the rising bill, the doctor must make all
efforts to transfer the patient to a public or less expensive private
hospital and personally make the necessary arrangements to
facilitate such a transfer.

121. GOOD CLINICAL PRACTICE REGARDING 2ND
OPINION & REFERRAL
o A doctor should himself be prepared to initiate a referral to a
colleague for second opinion when the situation demands or
when requested by patient.
o The referring doctor must make available all relevant information
and investigation results to the colleague, in good faith without
attempting to influence the decision of the colleague.
o The doctor giving the second opinion must deliver his
professional opinion without prejudice. He should then refer the
patient back to the principal doctor, agreeing or disagreeing, or
suggesting alternatives, preferably in confidence.
o In this age of super-specialisation, it is good medical practice to
refer a patient for definitive management by a colleague who has
special training or expertise in dealing with complex clinical
problem.

123. ISSUING MEDICAL CERTIFICATE
o Only Fully Registered Doctors can issue Medical certificate
(Sec 27, Medical Act 1971)
o Never issue prescription or medical sick certificate without
examining the patient first and making relevant notes in the
patient records.
o Never pre-sign sick certificates or prescription pads.
o Countersigning of MC for government servant is not
warranted (Pekeliling Perkhidmatan Bil 2 Tahun 2006)
o Regulation 24A,Medical Regulation 1974- certificate of
unfitness to attend court for persons who were unable to
attend court cases.

124. FORM 14-
CERTIFICATE OF
UNFITNESS TO
ATTEND COURT

126. ADVANCED DIRECTIVE
o It is a written directive by the patient that such treatment or procedure is
not to be provided in the circumstances which now apply to the patient
.This document is usually drawn by the patient and relative in the
presence of lawyer.
o However, it is still not legally binding in Malaysia.
o In an emergency, the medical practitioner can treat the patient in
accordance with his or her professional judgment of the patient's best
interests, until legal advice can be obtained on the validity of any Advance
Care Directive that may have been given by the patient.
o Where there are concerns about the validity or ambit of an Advance Care
Directive in a non-emergency situation, the medical practitioner should
consult the patient’s spouse or next of kin and the medical practitioner
should also consider the need to seek legal advice and all discussion
should be documented in patient’s medical record.

128. AOR DISCHARGES
o Pekeliling KPK Bil 11/ 2013: Prosedur Megenai pesakit Yang
Ingin Discaj Dari Hospital Atas Risiko Sendiri
o All AOR Discharges should be treated better than the usual
discharges:
i. To provide necessary information , medication, Medical
certificates, Review and follow-up documents
ii. To arrange for ambulance service as deemed necessary
subjected to availability
iii. To sign “AOR form”

130. GOOD SAMARITAN LAW
o A law that provides protection against claims of malpractice
for medical practitioners who render emergency care at the
scene of an accident except when gross negligence or willful
misconduct can be proved.
o It is the duty of the medical practitioner to provide first aid
during the emergency until the patient is handed over to
another treating or responding team.