Rekam Medis

Legal Aspects of Medical Records (in Indonesia).

With the growing world of health in Indonesia, has a medical record is no less important role in supporting the implementation of the National Health System (SKN). Medical records is very important in addition to diagnosis, treatment also for evaluation of health services, improving work efficiency through the reduction of mortality and motility as well as a more perfect patient care. Medical record must contain complete information regarding the process of medical services in the past, present & expected to happen in the future.
Ownership of medical records is often debated health care, because doctors assume that they are fully authorized to patients' medical records but the officer insisted on maintaining medical records file in the work environment. On the other hand, patients are often forced to take or read a file that contains a history of illness. This shows that the medical records is very important. Actually, it's who the medical record?
Complete medical records and carefully is a prerequisite for the proof in the case medikolegal case. In addition, the usefulness of medical records can be viewed from several aspects, among others:
- Administrative Aspects: Medical Record Administration has meaning because it concerns actions pursuant to the authority and responsibility for health.
- Medical Aspects: Medical Record mempunyayi medical value because the note is used as a basis for planning treatment and care to be provided.
- Aspects of the law: medical record has legal value because it comes to the guarantee of legal certainty on the basis of justice in an effort to enforce the law and the evidence to uphold justice.
- Financial aspects: Medical Record can be material to set the payment for health services.
- Aspects of the research: Record of medical research have value because they contain data or information as an aspect of research & development of science in the field of health.
- Aspects of Education: Record of medical education has value because it involves the chronological development of data information on medical services to patients who could be studied.
- Aspects of documentation: Medical Record dekumentasi have value because it is documented that the source should be used as an ingredient of accountability & reporting.
Medical records has a meaning as a written or recorded information about the identity, history, physical determination, laboratory / radiology, diagnoses, all medical services & action given to patients both ambulatory care, hospitalization, and emergency services provided to patients .
Therefore, medical records has a broader meaning than the listing of activities but also medical records management system. Implementation of medical records is a process that begins when the patient began to enter treatment at the advice of health services, medical data for medical services continued with the handling of medical record file includes Up & storage.
In the Indonesian legal system, known as the term 'materialism' which include understanding:
1. Goods (objects bodied, tangible objects) are visual objects, whether moving or not moving as building land, animals, cars etc..
2. Rights (not bodied objects, intangible objects) is a non visual objects such as accounts receivable, computer programs etc..
Medical records according to the Indonesian Legal Terminology can be classified as objects or goods (tangible objects). Medical record file is owned health care facilities, while the contents are the property of the patient.
According to Article 47 (1) no.29/2004 Law: "Documents sebagaimanan medical records referred to in Article 46 (1) of the Act no.29/2004 are owned by physicians, dentists or health-care facilities, while the content of the patient's medical record."
In the implementation of medical records, both activities, recording & storage stipulated in the Law no.29/2004, Permenkes no.269/2008, & standard procedures established health-care facilities, also in accordance with Indonesian medical ethics. So, it is clear that medical records should not be out of health care facilities.
As for third parties such as family, legal counsel, insurance, police, corporations, & the courts if you want to have a medical record can not be free, but must go through the procedure by showing the power of attorney (in writing) of the patients to ask for the contents of medical records and patient well- really in a state of conscious knowing that request with all the consequences of opening the secret about him, because the contents of medical records is not for free public consumption.
But if a patient had died, and who request copies of medical records is the legal representative of the patient's family, then it should not be given. This is to remember that patients who have died can not pass on the contents of medical records to the family because the contents of medical records are not items that can be traded and inherited, in addition to the oath that doctors must keep the patient even though the patient had died. What should be the benchmark is the letter of approval to provide information (the contents of medical records) which was signed by the patient, are always needed for every provision of information from medical records.

Can be concluded:
- Documents medical record is owned health care facilities
- Contents are the property of patients' medical records & made by doctors or dentists who provide services to these patients
- Medical Record should be retained and kept confidential by doctors, dentists, and leaders and staff from the health-care facilities
- The contents of medical records should only be known by patients or their parents (in this case when the patient is not yet an adult). Other parties (including family, legal counsel patients, companies, or health insurance) can know the content of patients' medical records when a written permit & aware of the risk of a secret known to him by others.
- If the patient has died, the medical record and its contents should not be given to anyone, including his heir.