discussing on medicolegal aspectin emergency dept

1. BASIC PRINCIPLE OF
MEDICOLEGAL MANAGEMENT
IN EMERGENCY DEPARTMENT
DR LEE OI WAH
KETUA PENOLONG PENGARAH KANAN (PERUBATAN)

2. CONTENT OF PRESENTATION
• Introduction to medical ethics
• Patient confidentiality
• Patient’s medical record
• Consent
• Chaperone
• Patient’s property
• ‘At-Own-Risk” Discharge
• Advanced Directive and End Of Care
• Management of OSCC cases

3. INTRODUCTION OF MEDICAL ETHICS
• “ Ethos ” – Greek word ; means CHARACTER
• The branch of philosophy which defines what is good for the individual
and society and establishes the nature of obligations or duties that
people owe themselves or to each other.
• Malaysia : governed by Medical Act 1971 ; oversee by Malaysian
Medical Council
• Guideline: Code of Professional Conduct , Good Medical Practice etc

4. CONFIDENTIALITY

5. 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 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

6. 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.
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

7. 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.

8. PATIENT’S MEDICAL RECORD

9. 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 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, The correction should then be entered in space available next to
the deleted statement, and signed clearly by the person making the correction.

10. 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.
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”.

11. 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 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).

12. 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.

13. CONSENT

14. DEFINITION
o Consent is a voluntary agreement with an action proposed by another person.
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.

15. 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

16. 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).

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

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.”

23. 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.

24. 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” .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 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.

25. 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

26. 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 patient is
incapable of giving consent.

27. 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.

28. CHAPERONE

29. 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.
o Chaperone : One who accompanies a physician during physical
examination of a patient with opposite gender

30. 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’

31. 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.

32. PATIENT’S PROPERTY

33. PEKELILING-PEKELILING BERKAITAN PENGURUSAN
WANG & HARTA BENDA PESAKIT
1. Surat Pekeliling Kewangan Bilangan 2 Tahun 2000 : Garispanduan
Menguruskan Harta Benda dan Wang Tunai Pesakit yang dikeluarkan
oleh KKM pada 18 Feb 2000
- ruj: KKM-58 / AM/ 017 (26)
2. Pindaan Garispanduan Menguruskan Harta Benda dan Wang Tunai
Pesakit yang dikeluarkan oleh KKM pada 9 Apr 2013 - ruj : (39) dlm
KKM 58/900/31 Jld 4

34. PADA DASARNYA
• Adalah menjadi tanggungjawab pihak hospital dan Klinik kesihatan untuk
memaklumkan kepada pesakit-pesakit bahawa mereka tidak dibenarkan untuk
membawa harta benda berharga seperti barang kemas dan seumpamanya apabila
dimasukkan ke dalam wad . Sekiranya mereka ada membawa bersama harta benda
berharga , mereka hendaklah mengaturkan sendiri untuk membawa pulang harta
benda tersebut melalui saudara-mara atau waris sendiri.
• Pihak hospital perlu menyediakan papan tanda yang diletakkan di tempat-tempat
strategik iaitu Jabatan Kecemasan dan Trauma, Bilik Daftar Masuk dan pintu masuk
semua wad :
PIHAK HOSPITAL TIDAK BERTANGGUNGJAWAB DI ATAS SEBARANG
KEHILANGAN , KECURIAN ATAU KEROSAKAN HARTA BENDA AWAM

35. PADA DASARNYA
• Bagi pesakit yang dimasukkan ke hospital dalam keadaan tidak sedarkan diri , pihak
hospital bertanggungjawab untuk menyimpan harta benda pesakit berkenaan
sehingga harta benda tersebut dapat diserahkan kepada pesakit atau waris /
penjaga pesakit yang sah .
• Bagi kes-kes di mana harta benda pesakit tidak dituntut , pihak hospital akan
menguruskan harta-benda tersebut sebagaimana yang dijelaskan dalam Garis
Panduan Pengurusan Harta Benda dan Wang Pesakit.
• Semua unit yang terlibat dalam pengurusan harta benda pesakit dikehendaki
merekodkan pergerakan harta benda pesakit di dalam Buku Daftar Sampul
Pengurusan Harta Benda Pesakit .

36. NOTA
No siri untuk
sampul harta
benda pesakit
dan ‘cable-tie’
telah
diperuntukkan
kepada setiap
PTJ dan
database
disimpan di
peringkat JKN.

37. NAMA PESAKIT : TARIKH & MASA :
NO KP/MYKID/PASPORT : RN : MASUK WAD
ALAMAT : NO TEL : MENINGGAL DUNIA
NAMA WARIS : RUJUK KELUAR
NO TEL WARIS : (SILA NYATAKAN )
A. SENARAI HARTA NO SIRI SAMPUL : NO "CABLE- TIE:
MATAWANG
BUTIRAN
WANG
BILANGAN CATATAN NAMA
JAWATAN
NO KP
TARIKH & MASA
TANDATANGAN
COP RASMI
NAMA
JAWATAN
PEGAWAI YANG MENERIMA & MEREKOD SAKSI NO KP
NAMA NAMA TARIKH & MASA
JAWATAN JAWATAN TANDATANGAN
NO KP NO KP COP RASMI
TARIKH & MASA TARIKH & MASA
TANDATANGAN PEGAWAI TANDATANGAN PEGAWAI
COP RASMIPEGAWAI COP RASMIPEGAWAI
NAMA
PEGAWAI YANG MENYERAH HARTA SAKSI JAWATAN
NAMA NAMA NO KP
JAWATAN JAWATAN TARIKH & MASA
NO KP NO KP TANDATANGAN
TARIKH & MASA TARIKH & MASA COP RASMI
TANDATANGAN PEGAWAI TANDATANGAN PEGAWAI
COP RASMIPEGAWAI COP RASMIPEGAWAI NAMA
MAKLUMAT PESAKIT/ PENJAGA / WARIS YANG MENERIMA HARTA ( SILA LAMPIRKAN SALINAN FOTOSTAT PENGENALAN DIRI)JAWATAN
NAMA NO KP
NO KP/PASPORT TARIKH & MASA
ALAMAT TANDATANGAN
TARIKH & MASA TERIMA COP RASMI
HUBUNGAN DENGAN PESAKIT
PEGAWAI YANG MENYERAH HARTA PEGAWAI YANG MENERIMA HARTA TARIKH
NAMA NAMA NO PENYATA PEMUNGUT
JAWATAN JAWATAN NO RESIT
NO KP NO KP
TARIKH & MASA TARIKH & MASA TARIKH
TANDATANGAN PEGAWAI TANDATANGAN PEGAWAI NO RESIT
COP RASMIPEGAWAI COP RASMIPEGAWAI
SALINAN JABATAN KECEMASAN / BILIK MAYAT/ KLINIK KESIHATAN JENIS DOKUMEN :
(SILA POTONG YANG TIDAK BERKAITAN) TARIKH & JABATAN PENERIMA:
DISPOSITION PESAKIT( √)
E. SERAHAN DI UNIT HASIL
PEGAWAI YANG MENYERAH HARTA
PEGAWAI MEMBUKA SAMPUL
SAKSI
G. SERAHAN WANG KE AKAUN AMANAH
H.SERAHAN HARTA KE BAITUL MAL
F.PENGURUSAN HARTA YANG TIDAK
DITUNTUT (SAMPUL DIBUKA PADA HARI
KE 30)
PEGAWAI YANG MENERIMA HARTA
BORANG PENGURUSAN HARTA BENDA PESAKIT
JABATAN KESIHATAN NEGERI PERAK
WANG TUNAI HARTA BENDA LAIN
CATATANBUTIRAN BARANG
D.SERAHAN KE HOSPITAL RUJUKAN/ POLIS ( SILA POTONG YANG TIDAK BERKAITAN)
C. TUNTUTAN HARTA OLEH PESAKIT / PENJAGA / WARIS YANG SAH
B. REKOD HARTA BENDA PESAKIT
I. SERAHAN DOKUMEN LAIN
Borang Pengurusan Harta Benda
Pesakit
4 salinan ‘carbonized’ :
• Salinan Jabatan Kecemasan / Klinik
Kesihatan / Bilik Mayat
• Salinan hospital yang menerima
rujukan / Polis
• Salinan Unit Hasil
• Salinan untuk rekod pesakit

38. Manual tatacara pengisian Borang
Pengurusan Harta Benda Pesakit :
membantu menyeragamkan dan
menjamin kualiti dokumentasi

39. DAFTAR SAMPUL PENGURUSAN HARTA BENDA PESAKIT
DI UNIT KLINIKAL
LAMP IRAN 2 A
UNIT:
Tarikh &
masa
Nama Pegawai
penerima
Jawatan
Pegawai
Penerima
Tarikh
& masa
Nama Pegawai
menyerah
Jawatan
Pegawai
Menyerah
Nama
pegawai
menerima
Jabatan
yang
menerima
Tarikh
& masa
Nama Pegawai
menyerah
Jawatan
Pegawai
Menyerah
Nama pesakit/waris
Hubungan
(pesakit/waris/pe
njaga)
BUKU DAFTAR S AMP UL Y ANG MENGANDUNGI HARTA/ WANG P ES AKIT
Bil Nama pesakit
No
KP/SB/Paspot
No siri sampul
harta / wang
Penerimaan harta/wang pesakit Serahan harta/wang pesakit Tuntutan harta / wang pesakit

40. DAFTAR SAMPUL PENGURUSAN HARTA BENDA PESAKIT
DI UNIT HASIL
LAMP IRAN 2 B
Tarikh &
masa
Nama Pegawai
penerima
Jawatan
Pegawai
Penerima
Tarikh &
masa
Nama Pegawai
menyerah
Jawatan
Pegawai
Menyerah
Nama pesakit/waris
Hubungan
(pesakit/wari
s/penjaga)
Tarikh &
masa
sampul
dibuka
Nama Pegawai
membuka
Nama saksi
No resit hasil /
Baitul mal
BUKU DAFTAR S AMP UL Y ANG MENG ANDUNG I HARTA/ WANG P ES AKIT DI UNIT HAS IL
Bil Nama pesakit No KP/SB/Paspot
No siri sampul
harta / wang
Penerimaan harta/wang pesakit Tuntutan harta / wang pesakit Pengurusan harta tidak dituntut

41. NOTIS PEMBERITAHUAN UNTUK
TUNTUTAN HARTA BENDA
NO SIRI NO KP/SB/PASPOT
Pengarah Hospital
Tarikh :
LAMPIRAN C
HARTA BENDA DAN WANG TUNAI PESAKIT YANG TIDAK DITUNTUT
Penama-penama di bawah adalah diminta menuntut wang tunai / harta benda mereka di Unit Hasil
Hospital …………………….. Pada waktu pejabat dalam tempoh 30 hari dari tarikh notis ini. Wang tunai
dan harta benda yang tidak dituntut dalam tempoh 30 hari selepas tarikh notis ini tidak boleh
dituntut dari pentadbiran hospital ini.
NOTIS PEMBERITAHUAN
NAMA DAN ALAMAT DESKRIPSI HARTA & WANG
Tandatangan :
Nama :
Jawatan :

42. MENOLAK RAWATAN (PHC)

43. CARTAALIRAN KERJA RESPON PRA DI LOKASI
KEJADIAN

44. Saya : No Kad pengenalan _ _
adalah pesakit sendiri /isteri/suami/penjaga /keluarga terdekat kepada pesakit :
Nama : No Kad pengenalan _ _
Yang beralamat di :
pada tarikh mengaku bahawa saya telah menolak perkhidmatan dan rawatan yang
ingin diberikan kepada saya / pesakit seperti nama di atas.
Saya mengaku bahawa tindakan saya ini bertentangan dengan nasihat yang telah diberikan oleh Pegawai
Petugas Perkhidmatan Ambulan Kecemasan dan faham tentang risiko-risiko yang bakal saya hadapi
sekiranya saya menolak perkhidmatan dan rawatan yang diberikan ini. Saya juga akan bertanggungjawab
sepenuhnya ke tas perkara-perkara yang mungkin akan berlaku akibat tindakan saya ini.
Nama : Nama :
No KP: No KP:
Hubungan dengan pesakit : Jawatan :
Tarikh : Tarikh :
Nama :
No KP:
Jawatan :
Tarikh :
(tandatangan saksi)
BORANG MENOLAK RAWATAN
(tandatangan pemohon)
(tandatangan petugas)

45. AOR DISCHARGE

46. 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”

47. PERLAKSANAAN AOR DISCHARGE

49. ADVANCED DIRECTIVE

50. 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.

51. MANAGEMENT OF OSCC CASES

52. (Pol. 59-Pin. 3/86)
POLIS DIRAJA MALAYSIA
PERMINTAAN UNTUK PEMERIKSAAN DOKTOR BAGI ORANG YANG TERLIBAT DALAM KES POLIS
Kepada PEGAWAI PERUBATAN YANG MENJAGA RUMAH SAKIT………………………………………...............................................................
Diminta tuan memeriksa……………………………….…………………………………………………………………………………...
No. K.P.P.N……………………………………. Umur…………………………… Jenis…………………………………………...
Keturunan………………………………………………………... Sebab peperiksaan dikehendaki:
(Potong mana-mana yang tiada dipakai)
(a) Orang salah (b) Orang cedera (c) Orang lain yang terlibat dalam suatu kes Polis
(d) Orang bangsat atau tidak berdaya upaya (di bawah seksyen 6, Bab 191)
(Lihat Borang Surat Akuan di bawah)
Tarikh dan jam dihantar .……….…………………………………………………………………………………………………………..
Diiringkan oleh …………………………………………………………………………………………………………………….……..
No. Aduan/Balai ………………………………………………………………………………………………………………………....
Keadaan dan butiran ringkas kes yang berkenaan…………………………………………………………………………………………
.Sama ada surat akuan dikehendaki atau tidak…..........................................................................................................................................
Sama ada yang berkenaan itu hendak dikawal atau tidak……………………………………………………………………….………..
Tarikh ………………………………………… Tandatangan………………………………………
K.P.D……………………………………………......
Ulasan Pegawai Perubatan jika surat akuan tidak dikehendaki……………………………………………………….. ……………….
………………………………………………………………………………………………………………………………………………
Tarikh………………………………………….
Pegawai Perubatan ……………………………………...
SURAT AKUAN DI BAWAH SEKSYEN 9 UNDANG-UNDANG ORANG BANGSAT
DAN TIDAK BERDAYA UPAYA (BAB 191)
Saya………………………………………………………………………………………………………………………………………
mengakui bahawa …………………………………………………………………………………………………………………………….
telah dibawa ke hadapan saya dalam kawalan Mata-Mata…………………………………………………………………………………....
didapati berdaya/tidak berdaya mencari sara hidup.
……………………………………………..
.
Tarikh………………………………………. Pegawai Perubatan………………………………….……
Pegawai Perubatan dikehendaki melaporkan kepada Polis atau Majistret dengan segeranya dalam hal keadaan merbahaya
yang membawa maut.
Apabila surat akuan dihendaki maka Mata-Mata yang mengiring hendaklah diarahkan supaya menunggu surat itu dikeluarkan
dan kemudian menyampaikannya terus kepada Ketua Polis Balai.
…………..
PNMB , K

53. BORANG 4
AKTA KANAK-KANAK 2001
[Subseksyen 20(1) dan (4)]
PENGEMUKAAN KANAK-KANAK KE HADAPAN PEGAWAI PERUBATAN
Kepada,
………………………………………………………
………………………………………………………
………………………………………………………
………………………………………………………
(Alamat hospital atau klinik kerajaan)
Seorang kanak-kanakyang dikenali sebagai ………………………………, lelaki /
perempuan. Umur : …………… * Sijil Kelahiran No. / Kad Pengenalan No.:
……………………………..….. telah diambil ke dalam jagaan sementara di bawah *seksyen
18 / subseksyen 20(4) Akta.
Saya berpendapat bahawa kanak-kanak itu memerlukan pemeriksaan atau rawatan
perubatan dan dengan ini mengemukakan kanak-kanak itu ke hadapan anda.
Menurut seksyen 21 Akta, anda:–
(a) hendaklah menjalankan atau menyebakan dijalankan pemeriksaan terhadap kanak-
kanak itu;
(b) boleh, pada memeriksa kanak-kanak itu dan jika dibenarkan sedemikian oleh
*Pelindung / pegawai polis, melakukan atau menyebabkan dilakukan
apa-apa tatacara dan ujian yang perlu untuk mendiagnosis keadaan kanak-
kanak itu; dan
(c) boleh memberikan atau menyebabkan diberikan apa-apa rawatan yang anda
fikirkan berikutan keputusan diagnosis itu.
DIBERIKAN di bawah tandatangan saya dan cop rasmi *Pelindung / pegawai polis
pada…………………. hari bulan ……………. tahun ………………..
…………………………………………….
(Tandatangan *Pelindung / pegawai polis)
Nama : ………………………………………
Alamat pejabat : ……………………………
Catatan * Potong mana-mana yang tidak berkenaan

54. (Nama pegawai perubatan)
(Nama hospital atau klinik kerajaan)
BORANG 8
AKTA KANAK-KANAK 2001
[Seksyen 24(2)]
PEMBERITAHUAN UNTUK MEMPEROLEH KEIZINAN BAGI RAWATAN
PERUBATAN KANAK-KANAK
Kepada,
……………………………………………
……………………………………………
……………………………………………
(Nama dan alamat *ibu / bapa / penjaga kanak-kanak / orang yang mempunyai kuasa untuk
mengizinkan rawatan perubatan kanak-kanak)
DENGAN INI DIBERITAHU bahawa …………………....................................... ,Pegawai
Perubatan di………………………………………… yang telah memeriksa
Seorang kanak-kanak yang dikenali sebagai………………………………… *lelaki /
perempuan. Umur : ……………………. * Sijil Kelahiran No. / Kad Pengenalan No.:
…………………………….….. berpendapat bahawa kanak-kanak itu –
(Catatan: Tandakan (/) pada kotak yang berkenaan)
Menjadi kewajipan saya di bawah perenggan 24(2)(a) Akta untuk memperoleh keizinan
bertulis anda bagi rawatan perubatan atau pembedahan atau psikiatri dilaksanakan
terhadap kanak-kanak itu.
DIBERIKAN di bawah tandatangan saya dan cap rasmi *Pelindung / pegawai polis
pada……..… hari bulan …………….tahun……………… .
…………………………………………….
(Tandatangan *Pelindung / Pegawai Polis)
Nama : ………………………………………
Alamat pejabat : ……………………………
mengalami penyakit, kecederaan atau keadaan serius
memerlukan pembedahan.
memerlukan rawatan psikiatri.

55. (Nama dan alamat hospital atau klinik)
BORANG 9
AKTA KANAK-KANAK 2001
[Seksyen 27]
PEMBERITAHUAN OLEH PEGAWAI PERUBATAN ATAU PENGAMAL PERUBATAN
BERDAFTAR
Kepada,
………………………………………………………
………………………………………………………
………………………………………………………
………………………………………………………
(Pelindung dan alamat pejabat )
Saya …………………………………….…………………………………………… Kad
Pengenalan No.: ……………………… seorang * Pegawai Perubatan / Pengamal
Perubatan berdaftar di……………………………………………………………...
…............................................................................................................................
2. Saya telah memeriksa atau merawat seorang kanak-kanak yang dikenali sebagai
……………………………………………………………. *lelaki / perempuan
Umur:…………………Alamat:………………………………………………………………..
…………………………………..……………….. Saya mempercayai atas alasan-alasan yang
munasabah bahawa kanak-kanak itu dicederakan dari segi fizikal atau emosi akibat
teraniya, terabai, terbuang atau didedahkan, atau teraniaya dari segi seks.
3. Oleh yang demikian, saya merujuk hal ini kepada Pelindung untuk tindakan lanjut.
**4. Untuk makluman tuan, saya telah mengambil kanak-kanak itu ke dalam jagaan
sementara.
Bertarikh………….hari bulan…………tahun…………….. .
……………………………………………………
(Tandatangan )
*Pegawai Perubatan / Pengamal Perubatan
Berdaftar)
Nama : …………………………………….
Alamat pejabat : ……………………………
……………………………………….

56. (Nama *Ibu / bapa / penjaga kanak-kanak / orang yang mempunyai kuasa untuk memberi keizinan)
(Nama dan alamat *Pelindung / pegawai polis)
(Nama kanak-kanak)
(Nama *Ibu / bapa / penjaga kanak-kanak / orang yang mempunyai kuasa untuk memberi keizinan)
Saya …………………………………………………………………………………….
Kad Pengenalan No.:…………………………… ……………………………………
telah menerima suatu salinan Pemberitahuan di bawah Subseksyen 24(2) Akta
daripada …………………………………………………………………………………
Saya telah dirundingi dengan sewajarnya tentang kehendak rawatan perubatan
atau pembedahan atau psikiatri yang akan dilaksanakan terhadap kanak-kanak
yang dikenali sebagai……………………………………………………………………
dan saya memberikan keizinan bagi rawatan sedemikian dilaksanakan terhadap
kanak-kanak itu.
………………………………………………………..
Nama: …………………………………….
Alamat: …………………………………...
…………..………………………….
KEIZINAN BAGI RAWATAN PERUBATAN ATAU
PEMBEDAHAN ATAU PSIKIATRI DILAKSANAKAN
TERHADAP KANAK-KANAK

57. SURAT KEBENARAN UNTUK MENERIMA KHIDMAT NASIHAT PERUBATAN
Saya ……………………………………………………………………………………………..
(nombor I/C:…………………………………….) telah dimaklum dan diterangkan oleh
Dr…………………………………………………………………………………yang berjawatan
……………………………………. dengan nombor I/C…………………………… berkenaan
dengan penjelasan pemeriksaan perubatan forensik dan pengumpulan bahan bukti.
Saya faham dan setuju bahawa sebarang hasil pemeriksaan dan bahan bukti yang
dikutip akan diberi kepada pihak polis untuk digunakan dalam mahkamah nanti.
Saya di sini memberi kebenaran supaya prosedur-prosedur berikut dijalani ke atas
saya sendiri / anak lelaki saya / anak perempuan saya / orang yang bernama
……………………………………………………………………...(No I/C / Passport / Sijil
Kelahiran: ……………………………………………….)
(Tandakan pada yang berkenaan):
Pemeriksaan fizikal pada tubuh badan saya/penama
Pemeriksaan fizikal pada bahagian genital dan/atau dubur saya/penama
Pengumpulan spesimen dari badan saya/penama
Pengumpulan spesimen dari bahagian genital dan/atau dubur saya/penama
Pengambilan foto pada sebarang hasil pemeriksaan yang dijumpai
pada tubuh badan saya/penama
Pengambilan foto pada sebarang hasil pemeriksaan yang dijumpai
pada bahagian genital dan/atau dubur saya/penama
Penerimaan rawatan jika dirasa perlu dari aspek perubatan
Tandatangan/cap jari pesakit/ibubapa pesakit/penjaga pesakit/pelindung pesakit:
Tandatangan saksi:
Nama:
Tarikh:
Nama:
Tarikh:

58. CLINICAL FORENSIC
EXAMINATION
FORM FOR
ALLEGED SEXUAL
ASSAULT
POLICE REPORT NO.: