State Administrative Law

by Dharma Na Gara

Medical records

Medical records

Doctors who practice medicine are obliged to make notes which must be made immediately after the patient receives services. Every health service must record and document the results of examinations, treatment, actions and other services that have been provided to patients.

Article 46 Indonesia’s Law Number 29 Year 2004 concerning Medical Practice determines:

• Every doctor or dentist in carrying out medical practice is obliged to keep a medical record;
• Medical records as intended in paragraph 1 must be completed immediately after the patient has finished receiving health services;
• Every medical record must contain the name, time and signature of the officer who provides the service or action.

From the provisions of Article 46 of the Medical Practice Law above, it is clear that the recording referred to is medical records. In practice, the term medical record has developed into other terms, namely:

1. Medical Document = Dokumen Medis;
2. Medical Notes = Catatan Medis;
3. Medical Record = Rekam Medis;
4. Health Record = Rekaman Kesehatan;
5. Personal Health Record = Rekaman Kesehatan Pribadi;
6. Medical Report = Laporan Medis.

Every recording (medical record) that is made must contain the name, time and signature of the doctor, dentist or certain health worker who provides health services directly. In the event that an error occurs in recording, correction must be made immediately by crossing out without removing the corrected note and initialing the doctor, dentist or health service worker concerned. Recording and documenting the results of examinations, treatment, actions and other services that have been provided to patients, is what generally called a medical record.

Organizing medical records at a health service facility is one way to measure the quality of service at that health service. Based on the data in the medical record, it will be possible to assess whether the service provided is of good quality or not, and whether it meets standards or not. For this reason, medical records were originally regulated in Minister of Health Regulation Number 749a/MENKES/PER/XII/1989 concerning Medical Records, then updated in Minister of Health Regulation Number 269/MENKES/PER/III/2008 concerning Medical Records. This is further regulated in the Regulation of the Minister of Health of the Republic of Indonesia Number 24 Year 2022 concerning Medical Records.

Meaning of Medical Records:

1. In article 1 letters 1, 6 and 7 of the Minister of Health Regulation Number 269/MENKES/PER/III/2008, what is meant by medical record is a file containing notes and documents regarding patient identity, examination, treatment, procedures and other services that have been provided to the patient. Notes are writings made by a doctor or dentist regarding all actions taken to patients in the context of providing health services. Documents are notes from doctors, dentists and/or certain health workers, reports of supporting examination results, daily observation and treatment records and all records in the form of radiology photos, imaging and electro-diagnostic records.

2. In the explanation of Article 46 paragraph (1) of Law Number 29 Year 2004 concerning Medical Practice, what is meant by medical records are files containing notes and documents regarding patient identity, examinations, treatment, procedures and other services that have been provided to patient.

3. In the Regulation of the Minister of Health of the Republic of Indonesia Number 55 Year 2013 concerning the Implementation of Medical Recorder Work, Specifically in Article 1 paragraph (2) Medical Records are files containing notes and documents regarding patient identity, examination, treatment, procedures and other services to patients at Health facility.

4. According to Ery Rustiyanto, medical records are who, where and how the patient was treated while in hospital to complete the medical record, it must have sufficient written data in a series to produce a diagnosis, guarantee, treatment and final result[1].

5. According to Gemala R. Hatta, a medical record is a file containing notes and documents regarding patient identity, examination, treatment, procedures and other services provided to patients in health service facility[2].

6. According to the Regulation of the Minister of Health of the Republic of Indonesia Number 24 Year 2022 concerning Medical Records, Medical Records are documents that contain the patient’s identity, examination, treatment, actions and other services that have been provided to the patient.

The content in Medical Records

According to the Regulation of the Minister of Health of the Republic of Indonesia Number 24 Year 2022 concerning Medical Records Article 26 paragraph 6 states:

The contents of the medical record as intended in paragraph 2 at least consist of:

1. Patient identity;
2. Results of physical and supporting examinations;
3. Diagnosis, treatment, and health service follow-up plans; And
4. Name and signature of the Health Worker providing Health services.

According to the Regulation of the Minister of Health of the Republic of Indonesia Number 24 Year 2022 concerning Medical Records Article 26 paragraph 7 states: Medical records as intended in paragraph (2) must be made by the person in charge of the service.

For further information, please consult your problem with us.

Source:

Zaeni Asyhadie, 2017, Aspek-Aspek Hukum Kesehatan di Indonesia, Rajawali Pers, Depok.

Peraturan Menteri Kesehatan Republik Indonesia No. 24 Tahun 2022 tentang Rekam Medis (Regulation of the Minister of Health of the Republic of Indonesia Number 24 Year 2022 concerning Medical Records).

[1] Ery Rustiyanto, 2009, Etika Profesi Perekam Medis dan Informasi Kesehatan, Graha Ilmu, Yogyakarta, h. 5.

[2] Gemala R. Hatta, 2008, Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan, Universitas Indonesia, Jakarta, h. 73.

by Dharma Na Gara

State Administrative Decision

State administrative decision was first introduced by a German scholar, Otto Meyer, with the term verwaltungsakt. This term was introduced in the Netherlands under the name beschikking by van Vollenhoven and C.W. van der Pot, which by some authors, such as AM. Donner, H.D. van Wijk/Willem Konijnenbelt, and others, are regarded as “de vader van het modern beschikkingsbegrip” (the father of the modern concept of beschikking).

In Indonesia, the term beschikking was first introduced by WF. Princess. The term of beschikking has been translated as decree, by E. Utrecht, Bagir Manan, Sjachran Basah and others, and as decision by WF. Prins, Philip M. Hadjon, SF. Marbun, and others. Djaenal Hoesen and Muchsan said that the use of the term decision might be more appropriate to avoid confusion between the definition and the term of decree. According to him, in Indonesia the term decree already has a juridical technical definition, namely as an MPR (People’s Consultative Council) decree that applies both externally and internally.

Some definitions of beschikking:

1. De beschikking is dus de wilsverklaring van een bestuurorgaan voor een bijzonder geval, gericht op het schepen van een nieuwe, het wijzigen of het opheffen van een bestaande rechtverhouding. (a decision is a statement of the will of a government organ to (execute) a specific matter, intended to create a new legal relationship, change or delete an existing legal relationship).

2. Beschikking; een wilsverklaring naar aanleiding van een ingediend verzoekschrift, of althans een gebleken wensch of behoefte.(Decision is a statement of will caused by a letter of application which submitted or at least a stated of desire or necessity).

3. Een beschikking is een individuelle of concrete publiekrechttelijke recht-beslissing: een beslissing van een bestuursorgaan, gebaseerd op een publiek-rechtelijke bevoegheid…. Geschapen voor een of meer individuen of met betrekking tot een of meer concrete zaken of situaties. Die beslissing verplicht mensen of organisaties tot iets, geeft ze bevoegdheden of geeft ze annspraken. (Beschikking is a public legal decision that is concrete and individual: the decision comes from a government organ, which is based on the authority of public law…. Was made for one or more individuals or regarding to one or more cases or circumstances. The decision imposes an obligation on a person or organization, granting authority or rights to them.

Based on Article 1 point 9 of Law Number 51 year 2009 regarding the Second Amendment of Law Number 5 year 1986 regarding the State Administrative Court, the State Administrative Decision (Keputusan Tata Usaha Negara/KTUN) is defined as: “a written stipulation issued by the State Administration Agency or Official which contains state administrative legal action based on the applicable laws and regulations, which is concrete, individual, and final and caused legal consequences for a person or civil legal entity.

Sample case:

1. Mr. A having his address at Cengkareng, West Jakarta, owns a piece of land. Once upon a time there was another party (Mr. B) who claimed that the land belonged to him. Mr. A feels that he owns the land because he has a right to use certificate dated November 1987, while Mr. B has proof of a right to use certificate in his name which has expired since 1982. Because there was a dispute between Mr. A and Mr. B, then the mayor intervened by sending a letter invitation to Mr. A to resolve the dispute. However, Mr. A, who feels that there is no need for another party to intervene, has refused the mayor’s invitation letter, moreover Mr. A felt that he has been harmed by the invitation letter, whom he couldn’t obtain an IMB (permit to build) on his land neither could sell his land. Therefore, Mr. A filed a lawsuit against the mayor through the Jakarta State Administrative Court.
2. Ms. A sued the Chief Village as Defendant I and the subdistrict-head (Camat) as Defendant II. The reason for the lawsuit was the plaintiff objected to the installation of a nameplate (plank) which written “land dispute” on the land owned by Ms. A or the Plaintiff.

For more information, please consult your problem with us.

Source:

Dr. Ridwan HR, 2017, Hukum Administrasi Negara Edisi Revisi, Rajawali Pers, Jakarta.

by Dharma Na Gara

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