PRIVACY AND CONFIDENTIALITY OF THE MEDICAL RECORD

Document number
GATOT SOEBROTO
ARMY HOSPITAL

Issued date
2012

Revision Number

Page
1 of 3

Stipulated
Stipulated,
Gatot Soebroto Army Hospital Director

STANDARD
OPERATING
PROCEDURE
Komaruddin Boenjamin, MD, Urologist
Indonesian Armed Forces Brigadier General
The use
u of privacy, confidentiality and security are often confusing.
confusing
However, there are some important differences, such as:
1.

Privacy is "the right of individuals to be left alone, free from

intrusion or observation of the individual's personal things as
well as the right to information controlling certain personal
information and health information."

2.

Confidentiality is "certain restrictions on disclosure of personal

information. This includes responsibility for use, disclose or
release
lease information only with the individuals knowledge and
consent. "

DEFINITIONS

Confidential information may be written

written or verbal. Privacy means
respect for patients
patient privacy; secrecy (confidentiality)
(confid
means
liabilities save health information as confidential.
Privacy and confidentiality
confidentiality of information is a patients medical
record which should be noted in the medical record storage. Privacy
and confidentiality information in the medical records should be
necessar maintained to be known and understood by all health
necessarily
practitioners and prevent the abuse of such rights by the parties.

AIMS

1.

To achieve a success in providing information on the services

provided by medical personnel and paramedics.
param

2.

To protect the privacy and confidentiality of patients

patient medical
record information.

PRIVACY AND CONFIDENTIALITY OF THE MEDICAL RECORD

GATOTSOEBROTO
ARMY HOSPITAL

AIMS

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2 of 3

3.

Prevent access and disclosure of information in the medical

record that can affect law.

4.

All staffs know and understand that the information in medical

records is private and confidential; medical record disclosure
of information should run orderly and smoothly.

1.

Privacy and confidentiality of medical record

2.

All health practitioners must maintain the privacy and

confidentiality of medical record information.

3.

A information medical record contains the accordance with

privacy and confidentiality:
a.
b.
c.
d.
e.
f.
g.

POLICY

Identity
Results of interviews
Physical examination and ancillary
Diagnosis
Remedies
Medical measures
Development of the disease

4.

Regulation of the Minister of Health (Permenkes) number 269

/ Menkes /a / iii / 2008 about the medical record.

5.

Implementation guidelines and procedures of the hospital

medical records in Indonesia revision - 2, the Directorate
General of Medical Services, Jakarta, 2006.

1.

Cover Medical Record contains only numbers of medical

record without patient's identity (name, address, age, gender,
etc.)

2.

Medical record information requests over the phone can not be

served unless the treating physician, and the installation head
coaching director of medical services and head of nursing.

3.

medical record information requests by email or fax must be

given a note that if the medical record information is not up to
the beneficiary, the hospital is not liable.

PROCEDURE

PRIVACY AND CONFIDENTIALITY OF THE MEDICAL RECORD

GATOTSOEBROTO
ARMY HOSPITAL

Document number

Page
3 of 3

4.

request medical record information by third parties could be

given if there is a permit disclosure of medical information from
the patient or guardian who is entitled.

5.

Medical information requested by the patients parents in

cases of child abuse (child molestation by her parents) is not
allowed.

6.

delivery of medical records to the clinic / inpatient ward / and

others for the benefit of patients should be carried out by
officers.

7.

The medical record officers, doctors, nurses and other medical

practitioners should uphold the principle of privacy and
confidentiality of medical record information in accordance
with the oath of office.

8.

Medical record information may only be opened for the

purposes of:

PROCEDURE

RELATED UNITS

Revision number

1.
2.
3.
4.
5.
6.
7.

a.

The patient's health;

b.

Meet the request of law enforcement agencies in the

enforcement of court orders;

c.

Request and/or the patient's own consent;

d.

Request the institution/agency based on the provisions of

the legislation; and

e.

Research, education, and medical audit, all do not

mention the identity of the patient in accordance with the
SOP of medical record information disclosure.

Patient administration and medical information

Emergency department
Inpatient
Installation outpatient
All functional medical staff
Medical committee
Sub committee of the medical records