The hospital says my medical records are missing, or I think they were altered. What can I do in Malaysia?

In most medical claims, the records are the backbone of the case. They show what was done, when, and by whom. So it is alarming when a hospital says records cannot be found, when pages seem to be missing, or when the copy you receive looks different from what you remember.

Why do medical records matter so much?

Records are usually the best evidence of:

• the timing of assessments, observations and treatment;
• what the doctor knew and recorded;
• what risks were explained and what consent was given;
• who was involved.

Independent experts rely heavily on them. See evidence gathering.

How do I request my records?

1. Write to the hospital or clinic asking for a complete copy of your records, including nursing notes, observation charts, drug charts, imaging, lab results and consent forms.
2. Keep proof of your request and any reply.
3. Pay any reasonable fee requested and note the date you received the records.

See getting medical records.

What if the hospital refuses or says records are missing?

• Ask for an explanation in writing: what is missing, why, and what searches were done.
• Pre-action discovery: under Order 24 rule 7A of the Rules of Court 2012, an application for discovery of documents before proceedings begin is made by originating summons, supported by an affidavit setting out the grounds and material facts.
• Discovery in the claim: once a claim is filed, parties must disclose relevant documents, and the court can make orders if they do not.

Have a question about your own situation? Ask on WhatsApp

What are signs that records may have been altered?

From a clinician's perspective, possible warning signs include:

• entries written in a different pen, hand or style that do not fit the sequence;
• times that do not match other records, such as lab, imaging or pharmacy timestamps;
• additions squeezed between lines or at page ends;
• typed records whose audit trail is not provided;
• differences between an earlier copy and a later copy.

These are not proof by themselves. Late entries can be legitimate if clearly marked. A forensic document examiner or the electronic system's audit trail may be needed.

What if records really are missing or altered?

• A claim can still proceed. Witness evidence, your own notes and messages, later hospital records, and other documents can fill gaps.
• Under the Evidence Act 1950, section 114 illustration (g), the court may presume that evidence which could be and is not produced would, if produced, be unfavourable to the person withholding it. Whether the court draws such an inference depends on the circumstances.
• Deliberately altering records may also raise professional and criminal issues. Those are for the authorities and regulators, separate from your civil claim.

Common mistakes

• Making requests by phone only, without written proof.
• Writing on or annotating the original copies you received. Keep a clean copy.
• Accusing staff of tampering publicly before evidence is examined.
• Waiting too long; records may be harder to trace over time.

When to speak to a lawyer

If a hospital refuses to provide records, says they are missing, or you believe they were changed after a serious incident. You can contact us; every case depends on its facts.

Frequently asked questions

Can I get the electronic audit trail?

It may be requested, and in litigation the court can order disclosure of relevant electronic records.

The copy I got is incomplete. What should I do?

Write back listing what is missing, such as nursing notes or observation charts, and ask for them specifically.

Does a missing record mean the hospital is liable?

Not automatically. It may support an adverse inference, but you still need to prove your case.

Can I report suspected alteration?

Concerns about a doctor's conduct can go to the Malaysian Medical Council. Suspected crimes can be reported to the police. Take advice first.

Should I keep my own notes?

Yes. A diary, messages and photos made at the time can be valuable evidence.

Sources & fact check

Legal points in this article were checked against the primary sources below. The law can change; this is general information, not legal advice.

1. Rules of Court 2012 (P.U.(A) 205/2012), text published by the Malaysian Bar, including Orders 12, 13, 18, 19 and 93
2. Evidence Act 1950 (Act 56), including section 114A, AGC Laws of Malaysia
3. Private Healthcare Facilities and Services Act 1998 (Act 586), Ministry of Health copy
4. Malaysian Medical Council, Code of Professional Conduct 2019

Fact-checked on 17 Oct 2026