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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.