MOH/S/RAN/68.13(HB)

MANUAL FOR DOCUMENTINGDIAGNOSIS IN PER-PD 301

Health Informatics CentrePlanning DivisionMinistry of Health Malaysia

MANUAL FOR DOCUMENTINGDIAGNOSIS IN PER-PD 301

Health Informatics CentrePlanning DivisionMinistry of Health Malaysia

Health Informatics CentrePlanning Division

Ministry of Health Malaysia

MANUAL FOR DOCUMENTING DIAGNOSIS IN PER-PD 301

All rights reserved. No part of this document may be reproduced or trasmitted, in any form or by any means,electronic, photocopying or otherwise without prior written permission from the Ministry of Health, Malaysia

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Health Informatics CentrePlanning DivisionMinistry of Health Malaysia

ISBN : 978 - 967 - 0399 - 70 - 6

Date created: October 2012First Edition: January 2013Second Edition: November 2013

Copyright @ Ministry of Health Malaysia 2013

CONTENT

1. INTRODUCTION 5

2. OBJECTIVES 5

3. AREAS TO BE FILLED IN PER-PD 301 (WITH DEFINITION) 5

4. GENERAL INFORMATIONS TO CONSIDER IN DOCUMENTING DIAGNOSIS 7

5. SPECIFIC INFORMATIONS TO CONSIDER IN DOCUMENTING DIAGNOSIS 8A. CERTAIN INFECTIOUS AND PARASITIC DISEASES 8

B. NEOPLASMS 11

C. ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES 13

D. MENTAL AND BEHAVIOURAL DISORDERS 17

E. PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 19

F. CERTAIN CONDITIONS ORIGINATING IN THE PERINATAL PERIOD 23

G. SYMPTOMS, SIGNS AND ABNORMAL CLINICAL AND LABORATORY FINDINGS 25 NOT ELSEWHERE CLASSIFIED

H. INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES 26

I. FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES 31

6. WORKING COMMITTEE ON MANUAL FOR DOCUMENTING DIAGNOSIS IN PER-PD 301 33

5

INTRODUCTION

The aim of this manual is to guide housemen in documenting proper diagnosis. With the availability of this manual as a reference, it is hoped that the error in documenting diagnosis in PER-PD 301 form can be reduced.

OBJECTIVES

• Tointroduceadmission/dischargeform(PER-PD301)• Tofacilitatedoctorsonproperdocumentationofdiagnosis

AREAS TO BE FILLED IN PER-PD 301 (WITH DEFINITION)

MAIN DIAGNOSIS The condition, diagnosed at the end of the episode of health care, primarily responsible for the patient’s need for treatment or investigation

CAUSE OF DEATH All those diseases, morbid conditions or injuries which either resulted in or contributed to death and the circumstances of the accident or violence which produced any such injuries

UNDERLYING CAUSE The disease or injury which initiated the train of morbid events leading directly to death

6

OTHER DIAGNOSIS A disease that accompanies the main diagnosis and (CO-MORBIDITY) requires treatment and additional care, in addition

to the treatment provided for the condition for which the patient was admitted

COMPLICATION DIAGNOSIS A disease that appears during the episode of care, due to a pre-existing condition or arising as a result of the care received by the patient

EXTERNAL CAUSES OF The circumstances of the accident or violence which INJURY AND POISONING produced the fatal injury

FACTORS INFLUENCING Episode of health care or contact with health HEALTH STATUS AND services are not restricted to the treatment or CONTACT WITH HEALTH investigation of current illness or injury. EpisodesSERVICES may also occur when someone who may not currently be sick requires or receives limited care of services.

7

THE DO’S AND DON’TS IN DOCUMENTING DIAGNOSIS

DO’s• ProperdocumentationofMainDiagnosis• Legiblehandwriting• TodocumentallotherconditionsunderrelevantheadingofOtherDiagnosis• DocumentproceduresintheProcedurecolumn

DONT’S • Donotuseabbreviations• DonotwriteproceduresasMainDiagnosis

GENERAL INFORMATIONS TO CONSIDER IN DOCUMENTING DIAGNOSIS

• Toidentifytheunderlyingcausativeagent(i.e:organism,drugs,chemical,allergens,idiopathic,autoimmune)

• Tospecifysite(anatomicallocalisation)ofinvolvementandside(i.e:Leftor/andright)•Toindicateiftheconditionisacute/sub-acute/chronic,recurrent/persistentormild/moderate/

severe• Tomentioniftheconditioniscongenital/acquired,primary/secondaryorinfantile/juvenile• Tomentionlaboratoryfindingsi.e:Haematological,biopsy,histological(i.e:Sputumpositive/

negative pulmonary tuberculosis)• Tospecifythediagnosisfailingwhichtospecifysymptomsandsignsorreasonforencounter/admission(i.e:AdmittedforbloodtransfusionduetoanaemiawithunderlyingThalassaemia,admittedforchemotherapywithunderlyingbreastcarcinoma,infantofdiabeticmotheradmittedfor observation, baby born before arrival for observation)

A

8

SPECIFIC INFORMATIONS TO CONSIDER IN DOCUMENTING DIAGNOSIS

A. CERTAIN INFECTIOUS AND PARASITIC DISEASES

Maindiagnosis/underlyingcauseshallinclude:

1) General infection • Tospecifythecausativeagent• Tomentioncondition(i.e:Meningitis,acutegastroenteritis)orsite(pulmonarytuberculosis)• Toincludecomplicationwherenecessary(i.e:Cerebralmalaria,rupturespleen,etc)

Other diagnosis• Tomentionantibioticresistanceifpresent(i.e:MRSA,vancomycinresistant,etc)

Example:

Morbidity caseMain diagnosis Example 1

Group A streptococcal (causative agent) septicaemia (condition)

Example 2HIV (causative agent) diseasewith Candidiasis (complication) and Karposi’s sarcoma (complication)

Underlying cause N/A

Other diagnosis(co-morbid)

Hypertension

Other diagnosis Penicillin resistant

Complication N/A

Mainprocedure/surgery Blood culture & sensitivity

A

9

2) Tuberculosis • Tospecifysiteinvolved(i.e:Lung,spine,intestine,etc)• Tomentionmethodofconfirmation(i.e:Smear,cultureorhistology)

Example:

Morbidity caseMain diagnosis Smear positive (method of confirmation) pulmonary (site) tuberculosis

Underlying cause N/A

Other diagnosis(co-morbid)

Non-insulindependentdiabetesmellituswithoutcomplication

Other diagnosis N/A

Complication N/A

Mainprocedure/surgery Sputum for Acid Fast Bacilli (AFB)

Other procedure Chest X-ray

A

10

3) Viral hepatitis• Tospecifyacuteorchronic• Tospecifytypeofvirus(i.e:HepatitisAvirus,hepatitisBvirus,hepatitisCvirusorhepatitisE

virus)• Tomentioncomplicationwithorwithouthepaticcoma.• IfhepatitisBtomentionwithorwithoutdeltaagent(co-infection)

Example: Morbiditycase:Main diagnosis Acute hepatitis B (type of virus)withdeltaagent(co-infection)withhepaticcoma

(complication)

Underlying cause N/A

Other diagnosis(co-morbid)

Hypertension

Other diagnosis N/A

Complication N/A

Mainprocedure/surgery Abdominal ultrasound

11

BB. NEOPLASMS

Maindiagnosis/underlyingcauseshall• Specifyprimaryorsecondarysite• Specifysiteoforganinvolved(i.e:Middlelobeoftherightlung,rightupperquadrantofright

breast)• Specifybehaviour(i.e:Malignantprimary,in-situ,benign,malignantsecondary)• Specifymorphology(i.e:Squamouscellcarcinoma)• Specifymetastasis

Example:

Morbidity caseMain diagnosis Adenocarcinoma (morphology/behaviour) of head of pancreas (site)

metastasis to the liver (metastasis)

Underlying cause Chronic pancreatitis

Other Diagnosis(co-morbid)

Type II diabetes mellitus

Other diagnosis N/A

Complication Cholecystitis

Main procedure/surgery

N/A

12

BMortality case

Cause of death Bronchopneumonia

Underlying cause Adenocarcinoma (morphology/behaviour)oflowerlobeofleftlung(site)withmetastasis to the para-aortic lymph nodes (metastasis)

Other Diagnosis(co-morbid)

Chronic obstructive pulmonary disease

Other diagnosis N/A

Complication Anaemia of chronic disease

Mainprocedure/surgery N/A

13

C

C. ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES

Maindiagnosis/underlyingcauseshallinclude:

1) Endocrine

Disorderofgland:• Tospecifycongenitaloracquired.• Tospecifycondition(i.e:Thyrotoxicosis,hypopituitarism)• Ifthyroidglandinvolved,tospecifywith(diffuse,multinodularorsinglenodular)orwithout

goiter.• Ifconditionisduetodrug-induced,tospecifythenameofdrug.

Ifdiabetesmellitus:• Tospecifythetypei.e:Insulindependant(TypeI,juvenile-onset,etc)ornon-insulindependant

(Type II, adult onset, etc)• Tospecifycomplication(i.e:HyperosmolarHyperglycaemicState(HHS)withcoma,diabetic

ketoacidosis, renal complication, etc)• *Uncontrolled/unstablediabetesmellitusisreferringtoTypeI

14

C

Example:

Morbiditycase:Main diagnosis Type II (type)diabetesmellituswithnephropathy(complication)

Underlying cause N/A

Other diagnosis(co-morbid)

Ischaemic heart disease

Other diagnosis Smear negative pulmonary tuberculosis

Complication N/A

Mainprocedure/surgery N/A

Mortality caseCause of death Streptococcus pneumoniae septicaemia

Underlying cause TypeIIdiabetesmellituswithnephropathy

Other diagnosis (co-morbid) N/A

Other diagnosis N/A

Complication N/A

Mainprocedure/surgery Blood culture & sensitivity

15

C

2)Malnutritionandnutritionaldeficiency• Tospecifycondition(i.e:Kwashiorkor,nutritionalmarasmus,protein-energymalnutrition,etc)• Intheeventofmalnutritiontospecifyseverityofthecondition(i.e:Mild,moderateorsevere)• Tospecifytypeofvitaminormineraldeficiency• Tomentioncomplicationrelatedtonutritionaldeficiency

Example:

Morbidity caseMain diagnosis Example1:

Severe (severity)malnutritionwithmarasmus(condition)

Example2:Thiamine (type)deficiencywithWernicke’sencephalopathy(complication related to deficiency)

Underlying cause N/A

Other diagnosis(co-morbid)

N/A

Other diagnosis Severe dehydration

Complication N/A

16

C

Mortality

Cause of death Severe protein energy malnutritionUnderlying cause N/AOther diagnosis (co-morbid) N/AOther diagnosis N/AComplication N/AMainprocedure/surgery N/A

17

D

D. MENTAL AND BEHAVIOURAL DISORDERS

*There is no issue in documenting diagnosis related to mental and behavioural disorder other than psychoactive substance used/abused

Main diagnosis/underlying cause shall • Indicatethepsychoactivesubstancesused/abused(i.e:Alcohol,opioids,cannabinoids,sedative

or hypnotics, cocaine, tobacco, volatile solvents, hallucinogens, other stimulants)• Mentionthementalandbehaviouraldisordersduetothepsychoactivesubstanceused/abused(i.e:Acuteintoxication,harmfuluse,dependencesyndrome,withdrawalstate,withdrawalstatewithdelirium,psychoticdisorder,amnesicsyndrome,residualandlate-onsetpsychoticdisorder)

• Specifytheseverityofmentalretardation(i.e:Mild,moderate,severe,profound)• Indicatetheextentofbehaviouralimpairment(i.e:Noimpairment,minimalimpairment,significantimpairment)

18

D

Example:

Morbidity CaseMain diagnosis Alcoholic (psychoactive substances used)withdrawalwithdelirium(mental and

behavioural disorder due to the psychoactive substance used/abused)

Underlying cause Alcohol abuse

Other Diagnosis(co-morbid)

N/A

Other diagnosis N/A

Complication Delirium tremens

Mainprocedure/surgery N/A

Main diagnosis Profound (severity)mentalretardationwithsignificantimpairmentofbehaviourrequiringattention(extent of behavioural impairment)

Underlying cause Down’ssyndrome

Other Diagnosis(co-morbid)

N/A

Other diagnosis N/A

Complication N/A

Mainprocedure/surgery N/A

19

E

E. PREGNANCY, CHILDBIRTH AND THE PUERPERIUM

Maindiagnosis/underlyingcauseshallinclude:

1) Pregnancy

• Specifytypesofabortion/miscarriage(i.e:incomplete,complete,inevitable,etc)• Specifythesiteofectopicpregnancy(i.e:Tubal,ovarian,abdominal,etc)• Specifysiteofinfection(i.e:Vaginalcandidiasisinpregnancy,etc)• Specifypregnancy-relatedconditionsandcomplications(i.e:Pregnancy-inducedhypertension,

gestational diabetes mellitus, deep vein thrombosis complicating pregnancy, etc)Example

Morbidity caseMain diagnosis Vaginal candidiasis (site of infection specified) in pregnancy

Underlying cause Insulin dependent gestational diabetes mellitus (pregnancy related condition)

Other Diagnosis(co-morbid)

N/A

Other diagnosis N/A

Complication N/A

Mainprocedure/surgery N/A

20

E

Main diagnosis Ruptured cornual ectopic pregnancy (site of ectopic pregnancy)

Underlying cause N/A

Other Diagnosis (co-morbid)

N/A

Complication Hypovolaemic shock

Mainprocedure/surgery N/A

Mortality case

Cause of death Hypovolaemic shock

Underlying cause Ruptured uterus due to criminal abortion (types of abortion)

Other Diagnosis(co-morbid)

N/A

Other diagnosis N/A

Complication N/A

Mainprocedure/surgery N/A

21

E

2) Delivery and Childbirth

• Specifymethodofdelivery(i.e:Spontaneousvertexdelivery,assistedvacuumdelivery,electivelowersegmentcaesareansection)

• Specifynumberoffetus(i.e:Single,twin,etc)• Relevantcomplicationsduringdelivery

Example:

Morbidity caseMain diagnosis Spontaneous vertex delivery (method of delivery and number of fetus) with3rddegree

perineal laceration (complication during delivery)

Underlying cause N/A

Other Diagnosis(co-morbid)

N/A

Other diagnosis N/A

Complication N/A

Mainprocedure/surgery Examination under anaesthesia and repair

22

E

3) Puerperium

• Specifycomplicationsrelatedtopostpartumperiod(i.e:Postpartumhaemorrhageduetopuerperal sepsis)

Example:

Morbidity caseMain diagnosis Puerperal sepsis (complications related to post partum period)

Underlying cause Retained products of conception

Other Diagnosis(co-morbid)

N/A

Other diagnosis N/A

Complication N/A

Mainprocedure/surgery Evacuation and removal of products of conception

23

F

F. CERTAIN CONDITIONS ORIGINATING IN THE PERINATAL PERIOD

Maindiagnosis/underlyingcauseshallinclude:• Ifneonataljaundice,mustspecifythecauseofjaundice(i.e:NeonataljaundiceduetoABO

incompatibility)• Ifbabyispremature,tomentionthegestationalageandweight• Ifinjury,toindicatethesiteandeitherduetobirthtraumaorothercauses(pleasespecify)(i.e:Subarachnoidhemorrhageduetobirthinjuryorsubarachnoidhemorrhageduetofallfrom

bed)• Ifbirthasphyxia,tomentiontheAPGARscoreat1minuteand5minute• Ifbabyadmittedforobservationindicatethecondition/suspectedcondition• Toassociatemother’sconditionduringpregnancythataffectthebabywiththereasonfor

admission, treatment or observationExample:

Morbidity caseMain diagnosis Transitory hypoglycemia (baby’s condition)

Underlying cause Infant of diabetic mother (Diabetic mother - mother’s condition)

Other diagnosis (co-morbid) N/A

Other diagnosis N/A

Complication N/A

Mainprocedure/surgery N/A

Otherprocedure/surgery N/A

24

F

Mortality caseCause of death Sepsis due to Staphylococcus aureus infection

Underlying cause Prematureat30weeks,1800grams(baby’s gestational age and weight)

Other diagnosis (co-morbid) N/A

Other diagnosis Neonataljaundiceduetopretermdelivery(cause of jaundice)

Other diagnosis Respiratory distress syndrome

Complication diagnosis N/A

Mainprocedure/surgery N/A

Otherprocedure/surgery N/A

25

G

G. SYMPTOMS, SIGNS AND ABNORMAL CLINICAL AND LABORATORY FINDINGS NOT ELSEWHERE CLASSIFIED

ShouldONLYbeusedasmaindiagnosisif:• Casesforwhichnospecificdiagnosiscanbemadeevenafterallthefactsbearingonthecasehavebeeninvestigatedorforanyotherreason(i.e:Facilitynotavailable,patientrefuseforinvestigation, etc)

• Signsorsymptomsexistingatthetimeofinitialencounterthatprovedtobetransientandwhichcausescouldnotbedetermined

• Casesreferredelsewhereforinvestigationortreatmentbeforethediagnosiswasmade.

Example:

Morbidity caseMain diagnosis Pyrexiaofunknownorigin

Underlying cause N/A

Other diagnosis (co-morbid) N/A

Other diagnosis N/A

Complication N/A

External cause N/A

Mainprocedure/surgery N/A

26

H

H. INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES

• The diagnosis pertaining to this topic must specify the external cause1) Injury:

MainDiagnosis/underlyingcauseshallinclude:• Specifytypeofinjury(i.e:Fracture,dislocation,wound,internalorganinjury)• Specifysiteofinjury• If fracture, to mention if open or close• Ifinternalinjuryoccurs,tospecifybluntorpenetratinginjury

Externalcauseofinjuryshallinclude:• Patient’smodeoftransport(i.e:Pedestrian,motorcycle,car,etc)• Patient’srole(i.e:Rider/driverorpassenger)• Mechanismofinjury(i.e:Collisionwithcar,non-collision(skidded,roll-over,etc.),fall,assault,

etc)• Placeofoccurrence(i.e:School,home,road,highway,field,etc)• Activity(i.e:Sports,work,etc)• Intentionoftheevent(i.e:Accidental,self-harm,assault)

27

H

Example:

Morbidity caseMain diagnosis Open fracture (type of injury) mid shaft of right humerus (site of injury)

Other diagnosis Right ulna nerve cut

Other diagnosis Lacerationwoundatscalp

Other diagnosis (co-morbid) Hypertension

Complication diagnosis N/A

External cause Motorcycle rider (patient’s role and mode of transport)incollisionwithcar(mechanism of injury)onhighway(place of occurrence)onthewaytowork(activity)

Mainprocedure/surgery Openreductionandinternalfixationofrighthumerus

Otherprocedure/surgery X-ray of right upper limb

28

H

Mortalitycase:Cause of death Hypovolemic shock due to uncontrolled bleeding

Underlying cause Blunt spleenic rupture (type and site of injury)

Other diagnosis Lacerationwoundatscalp

Other diagnosis Hypertension

Other diagnosis (co-morbid) DiabetesmellitustypeIIwithcataract

External cause Pedestrian (patient’s role and mode of transport) hit by car (mechanism of injury)whilecrossingroad(activity)infrontoftrafficlight(place of occurence)

Mainprocedure/surgery Emergency laparatomy

2)Burn/corrosion:

Main diagnosis shall include- The degree of burn - Specificsiteofburn- Percentage of body surface area

Externalcauseofinjuryshallinclude:- Mechanismofburn(i.e:Thermalorchemical)- Placeofoccurence(i.e:Home,workplace,etc)- Activity(i.e:Cooking,working,etc)- Intentionoftheevent(i.e:Accidental,self-harm,assault,etc)

29

H

Example:

Morbidity caseMain diagnosis 20% (% body surface area) second degree burn (degree of burn)ofchestwall

and bilateral upper limb (specific site of burn)

Other diagnosis(co-morbid) Hypertension

Other diagnosis(co-morbid)

TypeIIdiabetesmellituswithoutcomplication

Complication diagnosis Pseudomonas aeruginosa burnwoundinfection

External cause Accidental (intention of the event) gas tank explosion (mechanism of burn) at home (place of occurence) during cooking (activity)

Mainprocedure/surgery Wound debridement under general anaesthesia

30

H

3) Poisoning

Main diagnosis shall - Specifytypeofpoison(i.e:Drug,chemical,medicament)

Externalcauseofpoisoningshallinclude:- Theintentionofevent(i.e:Accidental,suicide,homicide,adverseeffectintherapeuticuse)- Placeofoccurrence(i.e:Home,workplace,etc)

Example: Morbidity cases

Main diagnosis Pesticide (type of poison) poisoning

Other diagnosis (co-morbid) Acute exacerbation of asthma

Other diagnosis N/A

Complication N/A

External cause Accidental (intention of event) ingestion of pesticide at home (place of occurrence)

Mainprocedure/surgery Gastric lavage

31

I

I. FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES

Maindiagnosis:• Categoriesinthischaptershouldnotbetheprimarymorbidityormortalitydiagnosis• Mentionthereasonforencounterwithhealthcare(i.e:Generalmedicalcheck-up,routineexamination/investigationforspecificcondition,etc)

Episodesofhealthcareorcontactwithhealthservicesarenotrestrictedtotreatmentorinvestigationofcurrentillnessorinjury.Episodesmayalsooccurwhensomeonewhomaynotcurrentlybesickrequiresor receives limited care or services; the details of relevant circumstances should be recorded as the “main condition”.Examplesinclude:

a) Monitoring of previously treated conditionsb) Immunisation c) Contraceptive management, antenatal and postpartum cared) Surveillance of persons at risk because of personal or family historye)Examinationsofhealthypersonseg:forinsuranceoroccupationalreasonsf) Seeking of health-related adviceg)Requestforadvicebypersonswithsocialproblemsh) Consultation on behalf of a third party

32

I

Example:

Morbidity CaseMain diagnosis Adjustmentandmanagementofcardiacpacemaker

(reason for encounter with healthcare)

Underlying cause N/A

Other Diagnosis(co-morbid)

Sick sinus syndrome

Other diagnosis N/A

Complication N/A

FactorsInfluencingHealthStatusandContactwithHealth Services

N/A

MainProcedure/surgery Replacement of pacemaker battery

Main diagnosis Born before arrival for observation (reason for encounter with healthcare)

Underlying cause N/A

Other Diagnosis(co-morbid)

N/A

Other diagnosis N/A

Complication N/A

MainProcedure/surgery N/A

33

6. WORKING COMMITTEE ON MANUAL FOR DOCUMENTING DIAGNOSIS IN PER-PD 301

Dr.RahimahbtMohdAriffinSenior Deputy Director Planning Division

Dr. Md. Khadzir bin Sheikh AhmadDeputy DirectorHealth Informatics Centre (HIC)Planning Division

Dr.MawarbinAyubEmergency and Trauma PhysicianHospital Kuala Lumpur

Dr. Ruhayah bt OmarSenior Principal Assistant DirectorState Health Department, Kelantan

Dr. Mohamad Yurzi bin GhaniDeputy Director (Clinical III)Hospital Sultanah Nur Zahirah, Terengganu

Dr. Nur Shaema DarusAssistant DirectorHealth Informatics Centre (HIC)Planning Division

Dr. Azrulreezal Azannee bin Abdul WahabAssistant DirectorHealth Informatics Centre (HIC)Planning Division

Dr. Charlene Patricia MalukunMedicalOfficerHospital Queen Elizabeth I, Sabah

Mr. Anuar ZainalMedicalRecordOfficerMedical Development Division

Madam Nurul Huda bt RamlanMedicalRecordOfficerHealth Informatics Centre (HIC)Planning Division

34

Madam Fazlina Suriayanti bt FazilMedicalRecordOfficerHealth Informatics Centre (HIC)Planning Division

Mr. Mohamad Uzuman bin Nordin AliMedicalRecordOfficerHospital Sultanah Nur Zahirah, Terengganu

Mr. Azmi bin IbrahimAssistantMedicalRecordOfficerHospital Kuala Lumpur

Madam Normah bt Mohd ShariffAssistantMedicalRecordOfficerHospital Taiping, Perak

Mr. Rosdi bin IbrahimAssistantMedicalRecordOfficerHospitalRajaPerempuanZainabII,Kelantan

Madam Denisa JoilinAssistantMedicalRecordOfficerHospital Wanita dan Kanak-kanak Likas, Sabah

Miss Norlida bt OsmanAssistantMedicalRecordOfficerHospitalTanjungKarang,Selangor

Madam Nurul Adilla bt Mohamed TaibSemantic EngineerMIMOS BHD

Madam Saniah bt MohamedSemantic EngineerMIMOS BHD

MANUAL FOR DOCUMENTINGDIAGNOSIS IN PER-PD 301

ISBN 978 - 967 - 0399 - 70 - 6

9 789670 399706

MANUAL FOR DOCUMENTINGDIAGNOSIS IN PER-PD 301