OPERATING MANUAL AND SOPS

FOR PRIVATE MEDICAL CLINICS

(Private Healthcare Facilities and
Services Regulations 2006) (P.U.(A)137/2006)

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© The Federation of Private Medical Practitioners’ Associations, Malaysia 2006

All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic, mechanical, photocopying,
recording, or otherwise, without the prior permission of the copyright owner.

ISBN 983-43306-0-X

First published 2006

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INTRODUCTION

This Manual and SOPs have been prepared by the FPMPAM in conjunction with the Ministry
of Health Malaysia.

This Manual and SOPs is solely meant as a guide to facilitate the private practitioner to
comply with the administrative provisions of the PHCFS Act (1998) and Regulations (2006).
Users of this document are advised to make amendments that are relevant to their
individual practice. All amendments can be entered as footnotes at the bottom of the
relevant pages.

DISCLAIMER :
This Clinic manual and SOPS is an open-content collaborative document, prepared by the
FPMPAM. The structure of the document allows the user to alter its contents according to
the needs and requirements of individual clinics.

Please make sure that you understand that the information provided here is being provided
freely, and that no kind of agreement or contract is created between you and the FPMPAM
or the editorial board or any project administrators or anyone else who is in any way
connected with this document or related documents subject to your claims against them
directly. You are being granted a limited privilege to use this document for your own use
only; it does not create or imply any contractual or extracontractual liability on the part of
FPMPAM or any of its agents, members, organizers or other users.

Any of the trademarks, service marks, collective marks, design rights, personality rights or
similar rights that are mentioned, used or cited in this document is the property of their
respective owners. Their use here does not imply that you may use them for any other
purpose other than for the same or a similar informational use as contemplated by the
FPMPAM.

This document has been copyrighted with an ISBN reference. Users of this document are
requested to respect the obligations imposed by this reference and no part of this document
should be used for any other purpose other than that stated above.

Should the user of this document need specific advice (for example, medial, legal, financial,
or risk management) you are advised to seek a professional who is licensed or
knowledgeable in that area.

EDITORIAL BOARD
Dr Steven Chow Kim Weng
Dr Chang Keng Wee
Dr Ng Swee Choon

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CONTENTS

Incident Report Form 5

New Patient Register 7

Referral Register 8

Referral Form 9

Death Register 10

Notifiable Infectious Disease Register 12

Volunteer Register 14

Patient’s Medical Record Movement Register 17

Staff Register 18

Staff Roster 19

Feedback Form 21

Investigation of Grievance Report 22

Patient’s Medical Report 23

Consent for Operation/Procedure 24

Emergency Phone Numbers 27

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1.0 PLAN OF ORGANIZATION
It is the policy of the clinic to exhibit the organizational chart in the waiting area of
the clinic.

ORGANIZATIONAL CHART

Person-in-charge

Administrative Chief Clinic Assistant Accounts

Others Others

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2.0 OFFICIAL CLINIC HOURS
The official clinic hours in this clinic :

DAY OF WEEK CLINIC HOURS STATUS

Monday Walk-in/By appointments only

Tuesday Walk-in/By appointments only

Wednesday Walk-in/By appointments only

Thursday Walk-in/By appointments only

Friday Walk-in/By appointments only

Saturday Walk-in/By appointments only

Sunday/Public Holidays/
Walk-in/By appointments only
Drs-on-Leave

3.0 ORDER FOR DIAGNOSTIC PROCEDURE, MEDICATION OR TREATMENT

ORDERS
All diagnostic procedures, medication or treatment will be given only upon receipt of
a written or verbal order of a registered medical practitioner.

The generic name and dosage of all medications prescribed and dispend in this clinic
will be labeled upon the instruction of the Person-in-charge. It is the responsibility of
the Person-in-charge to inform the patient about its administration.

4.0 INCIDENT REPORTING

Any unforeseeable or unanticipated incidents such as death of patient, fires in clinic,

assault or battery of patient, malfunction; intentional or accidental misuse of patient
care equipment shall be reported to the Person-in-charge.

Clinic staff shall immediately inform the Person-in-charge of the incident upon
occurrence.

The Person-in-charge will document the details of the incident and obtain a written
statement from witnesses, if a witness is present.

Clinic staff shall inform the person-in-charge as soon as possible, of the incident
upon occurrence.

Original and copies of report, relevant patient notes and relevant documents shall be
kept in separate file for safe-keeping and future reference.

A report shall be sent to the Director General of health by registered post (within 10
working days) following the incident

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 INCIDENT REPORT FORM

Name of Person-in-charge

Designation

I/C No

Clinic Address

Date/Time
(dd/mm/yyyy)

Nature of Incident

Action taken

Witness Statement
Name of witness :

I/C No. :

Address :

Telephone No. :

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5.0 WRITTEN POLICY OF CLINIC

5.1 Registered Medical Practitioner

Only a registered medical practitioner registered under the Medical Act 1971
and holding a valid practicing certificate shall be allowed to practice in this
clinic.

Only registered practitioners who have a valid written contract between

himself/herself and the clinic shall be allowed to practice in this clinic.

All registered medical practitioners practicing in this clinic shall be responsible

for the quality and compassionate care and treatment of all patients seen by
him/her and shall at all time act in compliance with relevant existing laws and
regulations of Malaysia.

5.2 Procedure for Patients Registration, Attendance and Referrals

All new patients shall be registered in the patent register.

Patient’s information shall be entered as per regulation in the front sheet. Any
information that the patient has refused to divulge / or unable to provide,
shall be entered as “not available”.

Follow-up patients shall be registered in the follow-up continuation sheet

upon arrival.

All patients who are referred shall have their available information recorded in
the Referral and Death Register.

No staff shall divulge any patient information to any third party.

All patient information shall be strictly private and confidential.

FOOT NOTES

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 NEW PATIENT REGISTER

NAME OF CLINIC : _____________________________________________

ADDRESS : _________________________________________

_________________________________________

_________________________________________

Registration Registration Name of New patient I/C No. Person-in-

date No. charge

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 REFERRAL REGISTER

Referral Date Patient’s Name Patient’s Referred to Person-in-

Form No. Registration No. charge

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 REFERRAL FORM

Referral date / Time _____________________ Referral Form No. _______________

Patient’s name

Address

Date of Birth

Gender

I/C No.

Name of Doctor

Clinic Address

Telephone No.

Clinical summary

Provisional Medical Diagnosis

Current Medications

Known Allergies and Sensitivities

Patient’s Condition on Transfer

Referred to : Name of Healthcare Facility :

Name of Person Informed :

Signature

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 DEATH REGISTER

Time of Registration Cause of Person in-

Date Death Name of Patient I/C No No Death charge
(if known)

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5.3 Infection Control

All notifiable infection occurring in clinic staff shall be reported to the Person-
in-charge.

Clinic staff with notifiable infectious disease shall be required to attend

treatment as instructed by the Person-in-charge.

All notifiable infectious shall be recorded in a notifiable infectious disease

register.

Any reportable infectious disease among patient or staff shall be reported to

the Ministry of Health in the infectious disease notification form.

Staff with reportable infectious disease shall only be allowed back to work
upon clearance from the attending medical officer.

All staff shall comply with any directives or guidelines issued by the Director
General on managing infection control, especially during outbreaks of
infectious diseases.

Any equipment that has become contaminated during the treatment of an

infectious patient shall be withheld from use and appropriately disinfected
under the supervision of the Person-in-charge.

FOOT NOTES

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 NOTIFIABLE INFECTIOUS DISEASE REGISTER

Name of Date / Clinic Name of Staff / Type Date / Time Diagnosis of

Person- Time of Name/Address of Equipment of Detection Notifiable
in-charge report Infectious
Disease

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5.4 Use of Antibiotics

In the event of a notifiable infectious disease infection, the Person-in-charge

may order appropriate cultures shall be made to determine sensitivity of the
infecting organism.

Appropriate antibiotics prescribed for treatment of the reportable infectious

disease shall be recorded.

5.5 Use of Volunteers

This clinic will allow volunteers to work in its premises provided the volunteer
is a person with such qualification, training and experience in the relevant
healthcare profession.

All volunteers will have to apply in writing and appear for an interview with
the Person-in-charge.

Upon approval, the volunteers shall be registered in the Volunteer register.

Volunteers shall undergo a period of orientation and supervision as

determined by the Person-in-charge.

FOOT NOTES

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 VOLUNTEER TREGISTER

Name of Volunteer

I/C No.

Address

Telephone No.

Completed Questionnaire on
Health Status

Records of Assignment and

Work Hours

Current Job Description

In-Service Training and

Orientation Records

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 5.6 General Maintenance of the Clinic

This clinic shall be kept in good repair and shall provide a safe and
comfortable working condition for its entire staff.

All equipment will be regularly checked and maintained on a schedule

determined by the Person-in-charge.

5.7 Transportation of Laboratory Specimens

Laboratory specimens shall be transported and sent to authorize laboratories

as determined by the Person-in-charge.

All specimens shall be collected and kept in authorized containers supplied by

the laboratory.

All specimens shall be duly labeled with patient’s name, registration number,
and date of collection.

Specimen shall be sent to the authorized laboratory within 24 hours of

collection in sealed plastic bags accompanied by a completed test request
form.

All staff handling laboratory specimens must wear protective gloves and take
all necessary precautions to prevent direct contact with the specimen.

No food must be kept in the refrigerator where laboratory specimens may be

kept.

6.0 STAFF IDENTIFICATION

All clinic staff shall wear staff identification nametags during clinic hours.

7.0 BILLING PROCEDURE

If requested by the patient, it is the policy of the clinic to inform patients of the
details of their medical bills prior to treatment and to issue itemized receipt.

A copy of the Seventh Schedule (Professional Fees) shall be made available for the
patient’s reference.

8.0 PATIENT’S RIGHT

It is the policy of the clinic to inform patients about the nature of his medical
condition and any proposed treatment, investigation or procedure and the likely
costs of the treatment, investigation or procedure as part and parcel of his
consultation.

It is the duty of the patient to ensure that he has understood that all relevant
information pursuant to the above upon completion of the consultation.

All patients in the clinic will be treated with strict regard to decency.

A medical report shall be forwarded within two weeks upon request and upon
payment of the fee as per the Seventh Schedule (Professional Fees – Medical Report
Fee).

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9.0 PATIENT’S MEDICAL RECORD REGISTER

All patients’ medical records shall be kept in a safe and orderly fashion in the clinic.

No records shall be transferred out of the clinic without expressed approval of the
Person-in-charge.

Any movement of patient’s medical record shall be entered into the patient’s Medical
Record Movement Register.

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 PATIENT’S MEDICAL RECORD
MOVEMENT REGISTER

Date

Person-in-charge

Clinic Name

Clinic Address

Patient’s Reference No.

Patient’s Name

I/C No.

Reason for Movement

Record for Movement

Records moved to

Approved by (signature)

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 10.0 STAFF REGISTER

Information of all staff shall be entered into the Staff Register.

STAFF REGISTER
Status Permanent
Date Temporary

I/C No.

Age

Designation

Qualification

Record of Leave and Sickness

Record of Staff Reference

(Referees, Date and Source)

Results of Staff Appraisal

Record of Movement of
Temporary Staff

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 11.0 ROSTER FOR HEALTHCARE PROFESSIONALS / STAFF

The clinic shall maintain a roster of healthcare professionals / staff practicing at the
clinic.

STAFF ROSTER

Attending Doctor
____________________________________________________________________

Morning Afternoon Night Standby / On

Shift Shift Shift Call

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday / Public Holiday

Drs-on-leave

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12.0 GRIEVANCE MECHANISM

It is the policy of this clinic to have a grievance mechanism for patients. The format
of the grievance mechanism shall be documented in this Manual for reference of the
Person-in-charge and the clinic staff. A feedback form as determined by the
Person=in-charge shall be provided for the convenience of patients.

The mechanisms shall be as follows:

Any patient with a grievance shall be asked to first discuss his/her grievance with the
Person-in-Charge.

If this fails to resolve the problem, he/she shall be requested to lodge his/her
grievance in writing by filing the Feedback Form.

Upon completion of the Feedback Form, he/she shall then inform the senior staff of
the clinic who shall then receive and acknowledge receipt of the completed form.

The Staff-in-charge shall inform the patient that investigation shall be completed
within two weeks.

The staff shall then forward the Feedback Form to the Person-in-charge as soon as
possible.

The Person-in-charge shall conduct an investigation within two weeks upon receiving
the form and shall record his/her findings in the Grievance Investigation Report.

Upon completion of his/her investigations, the Person-in-charge shall inform the

patient of the findings.

If this does not resolve the matter, the Person-in-charge shall then inform the
patient that the clinic will arrange for the services of a mediator from the local
Private Practitioners’ Association or any other mediator that is agreeable tp both
parties to resolve the matter.

If this fails, the Person-in-charge will then refer the matter to the Director-General
for adjudication.

FOOT NOTES

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 FEEDBACK FORM

Name of Clinic

Name of Patient

I/C No.

Address

Telephone No.

Date and Time of Incident

Patient’s Comments

Signature

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 INVESTIGATION OF GRIEVANCE REPORT

Name of Person-in-charge

Designation

I/C No.

Clinic Address

Name of Patient

I/C No.

Clinic R/N

Date / Time (dd/mm/yyyy)

Address

Telephone No.

nature of Grievance

Investigation done

Witness Statement

Findings of Investigation

Findings Conveyed to Patient

Date
Time
By : Phone/Fax/In Writing

Outcome

Signature of Person-in-charge

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 13.0 PATIENT’S MEDICAL RECORD SYSTEM

The clinical shall maintain a medical record system of patients in a manner as

determined by the person-in-charge with the following information. If the patient is
unable or refuses to divulge any of the said information it shall be recorded as “Not
available.”

PATIENT’S MEDICAL RECORD

Registration No.

Name

I/C No.

Address

Date of Birth

Gender

Next of Kin/Legal Guardian

Clinical Notes

Medication Orders

Known Allergies and Drug

Sensitivities

Current Medication

Results of Relevant
Diagnostic Tests

For any special procedure, minor operation or anesthesia, the patient shall be required to
give written consent in the form and manner as set out in the Consent Form.

The Person-in-charge/Doctor performing the special procedure, minor operation or

anesthesia shall ensure that the Consent Form shall be signed before undertaking of the
above.

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 CONSENT FOR OPERATION / PROCEDURE
Name of Clinic :
Address

I, …………………………………………………………………………………………………. (Name of Patient/Parent/Guardian)

NRIC : ………………………………………………………………………….

Of : ………………………………………………………………………………………………………………………………………………………

*hereby consent / give consent for : ……………………………………………………………………. (name of patient)

(Relationship to Patient) …………………………………………………………………………………………….……. to undergo

the *operation / procedure of : …………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………….

Where the nature, effects of which, and the risks of the proposed and alternative course of action
have been explained to me by Dr : …………………………………………………………………………………………………….

*Personally/through the interpretation of : …………………………………………………………………………………………

Who has, to the best of his/her ability translated to me in the ……………………………………….. language/
dialect.

I, also consent to such further or alternative operative measures or treatment as may be found
necessary on medical grounds during the course of the operation / procedure and to the
administration of general, local or other anesthetic for these purposes. I further consent to any
disposition deemed proper by the staff of the clinic, of the parts and tissues removed in the
process of performing such procedures.

Patient’s Signature / Thumbprint

Name :
Date :

Patient’s Guardian’s Signature/Thumbprint

(For minors and the mentally incapacitated only)
Name :
Date :

Witness Name :
Designation : Doctor’s Name :
Signature : Signature :
Date : Date :

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14.0 DISASTER PREPAREDNESS
In the event of a disaster in the vicinity of the clinic, the Person-in-charge or an
appointed member of the clinic shall immediately inform relevant local authorities.

All staff that is contactable shall be called back to the clinic.

Clinic shall be cleared of all non-emergency patients.

A suitable area of the clinic will be prepared to receive and provide basic life support
for emergency patients.

Emergency treatment equipment will be moved into the emergency treatment area.

Ambulance and the nearest hospital will be informed of the transport and arrival of
patients.

15.0 BASIC EMERGENCY CARE SERVICES

It is the policy of this clinic to provide basic emergency care services to any
occasional emergency patient who comes or is brought to the clinic.

The nature and scope of such emergency care services provided in this clinic are
i. Basic life support (as per UK Standard)
ii. Any other measures in accordance to this clinic’s capabilities as determined by
the Person-in-charge

Acceptance of patients for such emergency care services shall be determined by the
Person-in-charge or the Doctor present in the clinic.

Upon transfer of the patient to another healthcare facility, appropriate record of the
patient shall be kept in the Referral Register.

The procedure for providing emergency medical care services/Basic Life Support
shall be as follows:

16.0 FLOW CHART FOR BASIC LIFE SUPPORT (BLS1)

COLLAPSED PT

SUMMON HELP

CHECK RESPIRATION VE
+ VE
STABILISE SEND TO
CLEAR AIRWAY
NEAREST HOSP.

CALL 991
TELEPHONE CONTACTS
1. NEAREST HOSPITAL ______________
30 CHEST COMPRESSIONS ______________________________

2. NEAREST AMBULANCE
MOUTH TO MOUTH
SERVICE _______________________
______________________________
2 BREATHE 30 COMPRESSIONS

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17.0 THE PROCEDURE FOR BLS1 IN THIS CLINIC IS AS FOLLOWS:
1. Lie patient flat in an open space, and feel for the pulse and observe the
respiration. If there is a pulse, take the BP. If there is no pulse, begin BLS.
2. Take brief history from any accompanying persons. Exclude anaphylaxis.
3. Instruct available staff to get more help immediately. Call ambulance
service.
4. Loosen all of the patient’s clothes, and thumb patient’s chest as hard as
possible (Thumpversion)
5. Commence oxygen via a mask if patient is breathing spontaneously, using a
times.
6. If no spontaneous breathing. Breathe hard into the mouth. Maintain airway at
all times.
7. Arrange transfer him to nearest hospital as soon as possible.
8. Telephone Emergency Department of the nearest hospital and inform
receiving person. Record name of receiving person, time of call, time of
transfer, patient’s condition.

18.0 THE PROCEDURE FOR PATIENTS REQUIRING BLS ( 2 ) (FOR PATIENTS

REQUIRING INTRAVENOUS SUPPORT)

1. Lie patient flat in an open space, and feel for the pulse and observe the
respiration. If there is pulse, take the BP.
2. If peripheral vein is accessible insert IV needle/cannula immediately.
3. Take brief history from any accompanying persons. Quickly assess blood loss
and injuries.
4. Apply pressure bandages/tourniquet (if possible) to decrease major bleeding.
5. Instruct available staff to call for help immediately. Call ambulance
service.
6. Administer oxygen by mask, if patient is in respiratory distress, using a
oro-pharyngeal airway + mask.
7. If no spontaneous respiration, breathe hard into the mouth. Maintain airway at
all times.
8. If no pulse or spontaneous respiration, commence BLS1 immediately.
9. Arrange transfer him to nearest hospital as soon as possible.
10. Telephone Emergency Department of the nearest hospital and inform
receiving person. Record name of receiving person, time of call, time of
transfer, patient’s condition.

FOOT NOTES

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 19.0 EMERGENCY CALL AMBULANCE

EMERGENCY PHONE NUMBERS

Nearest Police Department

Ambulance

Nearest Hospital

Nearest Fire Department

Doctors/Staff members
Contact details as
determined by
the Person-in-charge

FOOT NOTES

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 20.0 PHARMACEUTICAL SERVICES
Policy Statement: The Head of Pharmaceutical Services/Person-in-charge shall abide
by these protocols.

Head of Pharmaceuticals
Services
(Name of Person)

Responsibility To direct, coordinate and supervise all activities relating to pharmaceutical

services, which includes the compounding of drugs and shall ensure the
provision of a comprehensive pharmaceutical services within the private
medical clinic.

Control and Accountability All medications shall be purchased from authorized pharmaceutical
companies and shall be duly recorded in the Stock Register as determine by
the Person-in-charge. All poison items shall be recorded in the Poison Book.

Distribution No medications shall be dispensed to any patient without authorization of

the Person-in-charge.

Storage and Quality All medications shall be stored in clean and sanitary area and shall not be
Assurance subjected to detrimental changes in temperature and humidity.

Poison Book The prescription and dispensing of all schedule medications under the Poison
Act shall be recorded in the Poison Book as prescribed

DDA Book The prescription and dispensing of all schedule medications under the
Dangerous Drugs Act shall be recorded in the DDA Book as prescribed

21.0 REGISTERS AND RECORDS OF PATIENTS (RADIOLOGICAL OR DIAGNOSTIC

IMAGING SERVICES)
The clinical shall maintain a record in relation to the radiological or diagnostic-
imaging studies performed on any patient as follows ;

Name of Clinic Requesting Test

Date of Dispatch of Results

Radiology laboratory Identification Number

Date and Time of Receipt

Date and Type of Test Performed

Person-in-charge

Test Results

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 22.0 SOCIAL / WELFARE CONTRIBUTION

The policy for social and welfare contribution of this clinic is as follows:

No Type of Social or Welfare Clinic Policy:

Contribution
All requests shall be decided on a case-to-case basis by the
Person-in-charge.
The Person-in-Charge may request for supporting evidence to
justify the request for discounts or exemption of fees.

1 Discount or Exemption from charge Persons eligible:

or fee Homeless, inmates of NGO old folk’s home, orphanages and
(i) Discount on Professional Fees any other persons deemed fit by Person-in-charge.
(ii) Exemption of fees for simple
consultation
(iii) Exemption of fees for simple
medical reports, referral letters

2. Provision of Emergency Care for Poor Persons eligible:

Patients Homeless, inmates of NGO old folk’s home, orphanages and
(i) Basic life support any other persons deemed fit by person-in-charge.
(ii) Referral to Government
Hospitals

3. Public Education (i) This clinic when specially requested and with sufficient
notice will provide public education talks and participates
in activities organized by NGO’s and government linked
organizations.

(ii) Public education talks to school children, Pregnant

mothers, patient support groups.

4. Miscellaneous (i) Cash donation up to a limit of RM …………… per annum as

determined by the Person-in-charge.

FOOT NOTES

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