Category Archives: Quality

JCI Standard MCI.13 – Use of standardised symbols and abbreviations

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The Joint Commission International (JCI) Standard MCI.13 is about the uniform use of standardised diagnosis codes, procedure codes, symbols, abbreviations (which includes a “do not use” listing), and definitions in a hospital which supports data aggregation and analysis and which facilitates comparison of data and information within and among organisations by using such standardised terminology, definitions, vocabulary, and nomenclature consistent with recognised local and national standards.

I shall be writing in the context of what a Health Information Management (HIM) / Medical Records (MR) practitioner on a need-to-know and what-to-do basis about this standard and its intent. To write all about the intents of this standard will take several posts, and I do not wish to be publishing text-book material here. I only plan to blog about what you need to know as an HIM/MR practitioner and what you need to plan and implement for your role as a HIM/MR practitioner, from the perspective of a quality practitioner with the background of as a HIM/MR practitioner.  I do not intend to publish a long posts, so this post is all about an official (approved) abbreviation list and the first post of a series of posts on the JCI Standard MCI.13, perhaps covering 2 or 3 more posts.

I believe every hospital  should establish a policy to maintain an official (approved) abbreviation list as to which abbreviations, acronyms, and symbols (and their meanings) can be documented in the patient record.

One does not wait for his or her hospital to be seeking JCI or other agency hospital quality assurance accredited status before embarking on a policy and an approved abbreviation list.

Here I am listing tasks for the HIM/MR practitioner and the Medical Records Committee (MRC) of a hospital :

  1. the HIM/MR practitioner should initiate an approved abbreviation list for discussion during a MRC meeting if he or she finds there in no approved abbreviation list or if the existing one needs a much-needed revision
  2. the MRC should set a dateline for medical-staff of the hospital to review and submit a revised list by distributing the existing list
  3. if there is no existing list, the HIM/MR practitioner should source for a sample list which can be downloaded from many Internet websites (check for copyright information; if written permission is required to reproduce, then it is wise to write to the copyright owner)
  4. modify and customise for local use, present at the MRC meeting and if approved for distribution, distribute to medical-staff of the hospital to review and submit a revised list by a set dateline
  5. the revised abbreviation list of an existing list or a newly created abbreviation list after review should be presented to the MRC
  6. the Chairman of the MRC who is usually a clinician, would then make it easier the task of final approval of this abbreviation list by using his or her influence among fellow clinicians in all medical disciplines of the hospital for consensus
  7. the abbreviation list is deemed finally an approved abbreviation list after one last meeting agenda to approve it officially at a scheduled MRC meeting
  8. the abbreviation list is forwarded to the hospital top management for final approval and signature before it is formated in an appropriate format and printed for distribution to all disciplines and patient care areas of the hospital
  9. a hospital policy must be created by the HIM/MR practitioner to document the approved abbreviation list as to which abbreviations, acronyms, and symbols (and their meanings) can be documented in the patient medical record of the hospital.

If your hospital is already JCI accredited, I am taking a guess the Management of Communication and

Information (MCI) Committee (MCIC) which has oversight on all matters pertaining to MCI, had initiated the approved abbreviation list of a revised existing list or created a new approved abbreviation list. The MCIC notifies the MRC about the necessity for compliance to JCI Standard MCI.13, and the MRC carries out tasks outlined as above for a hospital already JCI accredited or a hospital seeking JCI accreditation.

Usage of abbreviations, acronyms, and symbols found in the medical record during routine and/or random checks is monitored by the HIM/MR Department for any hospital. For JCI accredited or JCI accreditation seeking hospitals, checks are also done during a Medical Records  Review process session(s) and unapproved abbreviations, acronyms, and symbols  checked against an approved abbreviation list are documented and reported in a report to the Medical Records  Review Committee (MRRC) which in turn then forwards its meeting minutes highlighting anomalies from the report to the MCIC. The MCIC sends in a report or a letter to the MRC Chairman for his or her attention and appropriate action.

Before I end this post, I need to say that the JCI standards have not explicitly required an approved list of abbreviations. However, a “do not use” list which is a  “(JCI 2011) written catalog of abbreviations, acronyms, and symbols that are not to be used throughout a hospital – whether handwritten or entered as free text into a computer – due to their potentially confusing nature”, it is appropriate that a “do not use” list forms a part of the approved abbreviations list. You can view the Official Do Not Use List as it stands today released in 2004 by the Joint Commission (UnitedStates)  after you download it from
http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf (this link will open in a new tab of your current browser window).

My post on an approved abbreviation list ends here, and allow me to continue in my next post more on other concerns of the JCI Standard MCI.13

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Diagnostic procedures

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A Health Information Management (HIM) / Medical Records (MR) practitioner will find a series of diagnostic tests or diagnostic procedures – terms used interchangeably, incorporated into the medical record of a patient.

Diagnostic tests or procedures are necessary to formulate a medical diagnosis and the course of treatment based on a patient’s history and presenting symptoms. Diagnostic tests or procedures are also performed to determine abnormalities or disorders of various body systems to identify and to prioritise the treatments and procedures during periodic reassessment and evaluation of the patient’s expected outcomes.

In the post Plan Of Care (this link will open in a new tab of your current window) about individualised care plans, you can read to know about a patient’s care plan which is always related to his or her identified needs. But those needs may change as the result of clinical improvement or new information from a routine reassessment, for example from diagnostic tests such as abnormal laboratory or radiography results.

As diagnostic tests or procedures are expensive, they are prescribed usually selectively by the prescribing practitioner, who is either the doctor in most instances or other authorised  prescribing practitioners like advanced practice registered nurses who are authorised to order and perform certain diagnostic tests.

Diagnostic tests or procedures are either noninvasive or invasive. Noninvasive means the body is not entered with any type of instrument. The skin and other body tissues, organs, and cavities remain intact. Invasive means accessing the body’s tissue, organ, or cavity through some type of instrumentation procedure.

If you are working as a HIM/MR practitioner in a Joint Commission International  (JCI) accredited hospital or a hospital seeking JCI accredited status or infact at any hospital, the medical records show documentation evidence of doctors who had found an abnormality and had prescribed diagnostic tests or procedures to evaluate findings more closely. The JCI Standard COP.2.3 requires that such evidence be demonstrated in the patient’s medical record.

As the JCI Standard COP.2.3 intent statement specifically lists endoscopy and cardiac catheterisation diagnostic procedures, I shall provide some brief details on these diagnostic precudures.

Endoscopy is an invasive diagnostic technique using specialised instruments called endoscopes such as the sigmoidoscope, colonoscope, gastroscope, bronchoscope, and laryngoscope, for visual observation of internal organs through the intestinal tract. However, no incisions are made for routine endoscopy procedures.

 A team of doctors, nurses, and technicians perform a cardiac catheterisation procedure, which takes from 1 to 3 hours to obtain information about congenital or acquired heart defects, measure oxygen concentration, determine cardiac output, or assess the status of the heart’s structures and chambers. Therapeutic treatments may be done during the catheterisation to repair the heart, open valves, or dilate arteries.

Whatever the reason for diagnostic tests or procedures, diagnostic tests or procedures performed and the diagnostic findings (results) are always incorporated into the patient’s medical record. Such documentation on the appropriate forms will indicate details like the identity of the prescribing practitioner and his or her reason for performing the diagnostic and other procedures, if he or she had administered any anesthesia, dye, or other medications, type of specimen obtained and where it was delivered, vital signs and other assessment data such as patient’s tolerance of the procedure or pain and discomfort level as well as any symptoms of complications, patient or family teaching and demonstrated level of understanding  and written instructions given to the patient or family members about the diagnostic and other procedures.

A HIM/MR practitioner must will be able to differentiate between diagnostic and other procedures performed and the location of their diagnostic findings(results) from that for surgical procedures, a written surgical report or a brief operative note that can be found in the patient’s medical record.

References:
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Michelle AG & Mary JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

Anaesthesia plan in the patient’s medical record

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A Health Information Management (HIM) / Medical Records (MR) practitioner will find documentation of preoperative activities including each patient’s anaesthesia care which is planned and documented in the patient’s record.

The Joint Commission International (JCI) Standard ASC.5 specifically requires documentation of preoperative activities to include that each patient’s anaesthesia care is planned and documented in the patient’s medical record.

This is true for all patients in the preoperative phase in all hospitals, and not just for hospitals already JCI accredited or seeking JCI or other healthcare quality standards.

After the preoperative evaluation by an anaesthesiologist or another qualified individual as outlined in the post Anesthesia care must be given by a qualified individual (this link will open in a new tab of your current window), anaesthesia care is carefully planned and the anaesthesia plan is created,

The plan includes a list of drug choices and doses in detail, the method of administration, other medications and fluids, monitoring procedures, and anticipated postanesthesia care.

An HIM) / MR practitioner will find documentation of each patient’s anaesthesia care plan as shown in the sample General Anaesthesia Plan below documented in the patient’s medical record.

SAMPLE GENERAL ANAESTHESIA PLAN

Case
A 47-year-old woman with biliary colic and well-controlled asthma requires anaesthesia for laparoscopic cholecystectomy.

Preoperative Phase
Premedication
Midazolam, 1-2 mg IV, to reduce anxiety
Albuterol, two puffs, to prevent bronchospasm

Intraoperative Phase
Vascular access and monitoring
Vascular access: one peripheral IV catheter
Monitors: pulse oximetry, capnography, electrocardiogram, non-invasive blood pressure with standard adult cuff size, temperature
Induction
Propofol, 2 mg/kg IV (may precede with lidocaine, 1.5 mg/kg IV)
Neuromuscular blocking drug to facilitate tracheal intubation (succinylcholine, 1-2 mg/kg IV) or nondepolarizing neuromuscular-blocking drugs (rocuronium, 0.6 mg/kg)
Airway management
Facemask: adult medium size
Direct laryngoscopy: Macintosh 3 blade, 7.0-ID endotracheal tube
Maintenance
Inhaled aesthetic: sevoflurane or desflurane
Opioid-fentanyl: anticipate 2-4 mg/kg IV total during case
Neuromuscular blocking drug titrated to train-of-four monitor (peripheral nerve stimulator) at the ulnar nerve*
Emergence
Antagonize effects of nondepolarizing neuromuscular blocking drug: neostigmine, 70 mg/kg, and glycopyrrolate, 14 mg/kg IV, titrated to train-of-four monitor
Antiemetic: dexamethasone, 4 mg IV, at start of case; ondansetron, 4 mg IV, at end of case
Tracheal extubation: when patient is awake, breathing, and following commands
Possible intraoperative problem and approach
Bronchospasm: increase inspired oxygen and inhaled aesthetic concentrations, decrease surgical stimulation if possible, administer albuterol through endotracheal tube (5-10 puffs), adjust ventilator to maximize expiratory flow

Postoperative Phase
Postoperative pain control: patient-controlled analgesia – hydromorphone, 0.2 mg IV; 6-minute lock-out, no basal rate
Disposition: postanesthesia care unit, then hospital ward*Nondepolarizing neuromuscular blocking drug choices include rocuronium, vecuronium, pancuronium, atracurium, and cisatracurium.

*Nondepolarizing neuromuscular blocking drug choices include rocuronium, vecuronium, pancuronium, atracurium, and cisatracurium.

Source : Ronald DM & Manuel CP Jr 2011, Basics Of Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA

Do take note that sometime the anaesthesia plan may require modification of the plan which may include a specific requirement for an individual patient and thus may have implications for preparing additional equipment in the operating room for example, special equipment that may be kept in a cart dedicated to difficult airway management or in another instance, the patient’s responses to anaesthesia and surgery may also cause the anaesthesia plan to be adjusted.

When each patient’s anaesthesia care is planned and documented in the patient’s record, then you can be sure that medical record fully meets the two requirements of JCI Standard ASC.5

References:
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Ronald, DM & Manuel, CP Jr 2011, Basics Of Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA

Anesthesia care must be given by a qualified individual

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The patient undergoes preoperative nursing assessment (screening), and receives preanesthesia evaluation by an anaesthesiologist to place the patient in the best possible condition for surgery through careful assessment and thorough preparation. Assessment of the patient’s status before surgery establishes baseline data to direct interventions throughout the perioperative phases (the peroperative phase is a phase of the three perioperative phases).

Because anaesthesia carries a high level of risk, a qualified individual must conduct a preanesthesia assessment and preinduction assessment for each patient. For example (Ronald & Manuel, 2011), a patient undergoing coronary artery bypass graft has a significant risk of problems such as death, stroke, or myocardial infarction. A patient undergoing cataract extraction has a low risk of major organ damage.

An anaesthesiologist or certified Registered Nurse Anaesthetist (RNA) are two qualified anaesthesia providers who actively participate in conducting a preanesthesia assessment and preinduction assessment for each patient.

The main role of the anaesthesiologist or RNA is to ensure patient safety relative to the administration of anaesthesia. The anaesthesia provider:

  1. Obtains informed consent for anaesthesia services
  2. Performs a preanesthesia assessment that includes a thorough history, such as complications from previous anaesthesia, and physical examination
  3. Selects anesthetic agents

The patient’s preanesthesia assessment is for the use of postoperative analgesia. The preanesthesia assessment may be carried out some time prior to admission or prior to the surgical procedure or shortly before the surgical procedure, as in emergency and obstetrical patients.

Medical records from previous surgeries are reviewed when appropriate and feasible as part of the preanesthesia examination.

A separate preinduction assessment is performed to re-evaluate patients immediately before the induction of anaesthesia. Assessment evaluates if the patient has coexisting medical problems and if the surgery or anaesthesia care plan needs to be modified because of them. To anticipate the effects of a given medical problem, the anaesthesia provider then focuses on the patient’s physiologic stability from the physiologic effects of the surgery and aesthetic, and readiness of the patient for anaesthesia and occurs immediately prior to the induction of anaesthesia. For example, the anaesthesia provider may change (Ronald & Manuel, 2011) the anaesthetic plan to increase the induction dose of intravenous anaesthetic for a patient with poorly controlled systemic hypertension who is more likely to have an exaggerated hypertensive response to direct laryngoscopy to facilitate tracheal intubation.

When anaesthesia must be provided emergently, the preanesthesia assessment and preinduction assessment may be performed immediately following one another, or simultaneously, but are documented independently. The urgency (Ronald & Manuel, 2011) of a given procedure (e.g., acute appendicitis) may preclude lengthy delay of the surgery for additional testing, without increasing the risk of complications (e.g., appendiceal rupture, peritonitis).

The Joint Commission International (JCI) Standard ASC.4 requires documentation in a medical record for a preanesthesia assessment and a separate preinduction assessment performed to re-evaluate patients immediately before the induction of anaesthesia by “A qualified individual” who “conducts a preanesthesia assessment and preinduction assessment.” for every patient prior to surgery.

An Health Information Management (HIM) / Medical Records (MR) practitioner will find documentation of preoperative activities including preanesthesia assessment using the preoperative checklist and a separate preinduction assessment always entered in the patient’s medical record on the appropriate forms.  This is true for all patients in the preoperative phase in all hospitals, and not just for hospitals already JCI accredited or seeking JCI or other healthcare quality standards.

The preoperative checklist is used to document accurate completion of preoperative activities, including preanesthetic evaluation done (using the preanesthesia evaluation note). This checklist identifies assessments, medications, and other physical preparations that must be completed before the client is anesthetised.

The preanesthesia evaluation note is a progress note (Michelle & Mary, 2011) documented by any individual qualified to administer anaesthesia prior to the induction of anaesthesia. Includes evidence of patient interview to verify past and present medical and drug history and previous anaesthesia experience(s), evaluation of the patient’s physical status, review of the results of relevant diagnostic studies, discussion of preanesthesia medications and choice of anaesthesia to be administered, surgical and/or obstetrical procedure to be performed, and potential anaesthetic problems and risks; sometimes documented on a special form located on the reverse of the anaesthesia record.

An anaesthesia record is required to show preanesthesia medication administered, including time, dosage, and effect on patient, when a patient receives an anaesthetic other than a local anaesthetic.

Preanesthesia (and postanesthesia) evaluation progress notes are sometimes documented on a special form located on the reverse side of the anaesthesia record. This can prove helpful to anaesthesiologists so that no documentation elements are forgotten.

The preanesthesia progress notes and anaesthesia record provide the documentation of the administration of preoperative medications, and evaluation of the patient preoperatively in the medical record. The medical record of a patient must show evidence of a preanesthesia assessment and a separate preinduction assessment that was performed to re-evaluate the patient immediately before the induction of anaesthesia, both of which were conducted by an individual(s) qualified to do so. Such aforementioned evidence meets JCI requirements.

References:
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Michelle AG & Mary JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Ronald DM & Manuel CP Jr 2011, Basics Of Anesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

JCI Standard MCI.16 – Leadership and Planning, records and information are protected

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A hospital ensures to maintain the security and confidentiality of data and should be especially careful about preserving the confidentiality of sensitive data. The hospital is also usually expected to determine the level of security and confidentiality maintained for different types of information.

When the Joint Commission International (JCI) examines how a hospital practices in the area of information management at an overall level during a hospital accreditation survey, its surveyors would normally check how the hospital addresses the Standard MCI.16 which requires that “Records and information are protected from loss, destruction, tampering, and unauthorized access or use”.

Natural or man-made disasters could destroy paper-based or electronic patient records when heat, water, fire, or other damage is likely to occur. Medical records, other data and information should  be stored in locations that are secure and protected at all times.

fire door

Image credit: sandor.com.my

It is common for the record room to contain fire walls or at minimum fire doors that prevent a fire from spreading from one area to another. The file area should also have a sprinkler system in place in case of fire. What is often overlooked here in Malaysia is an enclosed top shelf to help protect them from water damage in the event of sprinkler system malfunction.

Health Information Management (HIM) / Medical Records (MR) practitioners here in Malaysia or elsewhere should check with their local fire departments on fire codes that dictate clearance needed between the ceiling and the shelves as well the space required between file rows. The file area should also contain a fire extinguisher and a fire pull switch, and staff must be trained in the use of each.

The official portal for the Fire and Rescue Department Malaysia (FRDM) classifies fires caused by paper as Class A Fire and fire caused by electrical sources as Class E Fire. The portal recommends fire and safety tips but I am listing among other tips those of which that will be applicable to HIM/MR departments here in Malaysia, namely to install smoke detectors on the ceiling, no smoking on premise (obviously prohibited in a hospital), and avoiding power supply extensions that burden the electric circuitry. An HIM/MR practitioner and his or her staff should familiarise with the easy steps to use a Fire Extinguisher (there is a poster for quick facts) as given in this portal.

floodRecords must also be protected from water damage due to malfunctioning sprinkler systems or flooding. Records should not be stored on the floor, as this presents a safety hazard to staff members and records could be damaged in the event of flooding. Records that are maintained in closed files are more protected from water damage than records located on open shelf units.

Medical information when documented and collected, is important for understanding the patient and his or her needs and for providing care and services over time. This information may be in paper or electronic form or a combination of the two.

A hospital must respect such information as important for patient care and establishes policies and procedures to address issues related to the security, and as such has implemented policies and procedures that protect such information from loss or misuse. A hospital must also respect the confidentiality of patient information, and thus also establishes policies and procedures to address issues related to confidentiality, and implements processes to prevent unauthorised access to confidential information.

A policy implemented by a hospital is a Medical Records Policy, that includes policy statements on matters like the security of medical records information, access to medical records and medical information and the process to gain access when permitted, either paper-based and electronically stored information or a combination of the two.

Standard Operating Procedures should be constructed to provide (i) procedures on security from loss due to natural and man-made disasters, and (ii) procedures on access to medical records and the process to gain access when permitted that protect such information from misuse (tampering) but also theft.

An effective process on confidentiality defines the following:

  • Who has access to information
  • The information to which an individual has access
  • The user’s obligation to keep information confidential
  • When release of health information or removal of the medical record is permitted
  • How information is protected against unauthorised intrusion, corruption, or damage
  • The process followed when confidentiality and security are violated

Patient information is protected from theft when only authorised personnel have access to the file area. For example, procedures that protect patient information areas would include processes such as :

  • if a HIM/MR staff member is not available in the file area to retrieve a record, the area must be secured
  • if the file area is locked, only those authorised to access the area should have a key or use authorised swipe cards (similar to those used for hotel rooms)
  • when the file area is not staffed (e.g., evenings, nights, weekends), procedures must be established to allow limited access to records
  • a nursing supervisor will be provided with a key to the file area and assigned responsibility for retrieving patient records if needed

One must not forget that patient information located in patient areas (e.g., nursing units) must be evaluated for protection against loss from fire, water, and theft.

Image credit : http://www.butdoctorihatepink.com/

Computerised health information also needs to be protected from loss due to fire, water, or theft. It is common to create a backup file of all computerised patient information and to store the backup file off site (at a location other than the facility). In the event of loss, the backup can be used to re-create patient information.

Patient medical records and other data and information should always be secure and protected at all times portable computer security (e.g., laptops, mobile devices, and so on). The risk of theft increases when someone can simply “walk off” with a laptop, resulting in stolen patient information. I have posted enough material on Bring Your Own Devices (BYOD) and Bring Your Own Cloud (BYOC) hazards in past posts of this blog on how hospitals and HIM/MR departments need to establish appropriate controls to address this issue.

I would think that a Contingency Plan by the HIM/MR department is necessary to respond to an emergency or other occurrence (e.g., fire, vandalism, system failure, and natural disaster) that damages paper-based and electronically stored information or a combination of the two.

For an HIM/MR working with Electronic Medical Records (EMRs), the Contingency Plan would address (Michelle AG & Mary JB 2011) a data backup plan and disaster recovery plan to create and maintain retrievable exact copies and to restore any loss of data to enable continuation of critical business processes in an emergency mode, ensure testing and revision procedures for periodic testing and revision of contingency plans, and include applications and data criticality analysis to determine the potential losses which may be incurred if components of applications and data were not available for a period of time.

I believe all said and done, that better protection of medical information will require efforts in improving public policy at a centralised command level if your hospital is part of a group of hospitals. The lack of uniform policies and procedures for the privacy and security of medical information creates particular problems for a group of hospitals’ organisation that serves its hospitals in multiple states and creates additional confusion for patients regarding their rights.

Overall, if security policies and procedures are not established and enforced, concerns might be raised about the security of patient information during legal proceedings. This could result in questioning the integrity of the medical record.

It is imperative that HIM/MR practitioners working in any hospital setting understand the importance of security and confidentiality of Protected Health Information (PHI) and medical records, and work towards understanding the uniform policies and procedures if any – or just his or her hospital policies and procedures, and ensures that medical records and other information are protected from loss or destruction, tampering and unauthorised access or use.

The implementation of the above measures would enable a hospital that had acquired JCI accreditation status or one that is seeking JCI accreditation status, to have met or fully meet the Standard MCI.16 and its two (2) MEs.

References:
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Michelle AG & Mary JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Official Portal Fire and Rescue Department Malaysia(FRDM), viewed 27 July 2012 <http://www.bomba.gov.my/main.php>