Medicolegal aspect of medical records

Examiner : dr. Arista Hardinisa Preceptor : dr. M Ainurrofiq

Lucky Pratama

(112.0221.144)

Randy Pratama
Ayuningdyah Chitra B

(112.0221.147)
(112.0221.148)

Intan Deniati
Yosie Puri L Titu Parfita R

(112.0221.155)
(112.0221.160) (112.0221.165)

Widya Dwi A

(112.0221.168)

Chapter 1

Foreword

Background
Medical Record Previously unnoted Law charge from patient

Medical record cant be used as an evident tools in court

Permenkes no 749 (1989)

Problems Identification
Definition, benefits, types, and the contents of Medical Record

Storage and removals of medical record

Law Aspects of medical record

As a valid evident tools in court

Purposes To know medicolegal General aspect of medical Purposes record in Indonesia

Special Purposes

A.To know the definition, history, benefits, types, and the contentsof medical record. b.To know the storage system, removals, and disclosure of medical records. c. To increase the knowledge of electronic medical record. d. To know the law aspects of medical record. e. To know whether medical record is a legitimate evident tools in court

Writing Benefits

- To increase the knowledge about benefits, types and the contents of medical record - To increase the knowledge about law aspects of medical record - To increase the knowledge about the need of making a medical record for doctors,patients, health service science development concern

Chapter II Literature Reviews

Definition of Medical Record

Peraturan Menteri Kesehatan Nomor 749A/MENKES/PER/XII/ 1989 The file contains records and documents about the identity of the patient, examination, treatment, action, and other services to patients in healthcare facilities.

Menurut PERMENKES No. 269/ MENKES/ PER/ III/ 2008

file containing the records and documents about the identity of the patient, examination, treatment, action and other services that have been given to the patient.

Ikatan Dokter Indonesia

recorded in writing or activity description of services provided by medical or health care provider to a patient.

History and Development of National Medical Record

Decision of the Minister of Health of Indonesia Number 031/Birhup/1972 which states that all hospitals are required to work on medical recording and reporting, and hospital statistics. decision of the Minister of Health of Indonesia Number 034/Birhup/1972 of Hospital Planning and Maintenance. "To support the Master Plan is good, then every RS is obliged: to have and maintain an up to date statistics, building medical record based on the provisions which have been established"

Keputusan Men.Kes.RI No. 134/MenKes/SK/IV/78, tgl 28 April 1978, tentang SOTK RSU. Sub Bagian (Urusan) Pencatatan Medik mempunyai tugas mengatur Pelaksanaan Kegiatan Pencatatan Medik. UU No. 23 tahun 1992 tentang kesehatan. PP No. 32 tahun 1996 tentang tenaga kesehatan. Adanya UU Praktik Kedokteran No. 29 tahun 2004.

PerMenKes RI No. 269/MenKes/Per/III/2008, tentang Rekam Medik (Medical Record).

The Benefit or Function of Medical Record

In the Minister of Health No. 749 of 1989 states that a Medical Record has five benefits, namely:
1. As a basic health care and treatment patient

2. As material evidence in lawsuits

3. Materials for research purposes 4. Basic payment of health care cost

5. Databases for statistical purposes

TUJUAN REKAM MEDIS

Menurut International Federation Health Organization (1992:2), rekam medis dengan tujuan:

Communication tool Sustainable patients health

Patient health evaluation Historic record Medicolegal Statistical purposes Research and educational purposes

Type of medical records

Conventional
Paper work, were written on by handwriting.

Electronic

Paper less and were written by typing in computer.

Medical records content

Workplace Pay grade Company address Orang yang bertangung jawabmenanggung biaya Insurance number Payment Full name Parents name Date of birth and birthplace Social security number occupation sex Marital status Ethnic

Finansial

Identitas

Medical
Data langsung Data dokter atau profesional lainnya

Social

Race Occupation Hobbies Family infomation Life style Behaviour

Medical Record Storage System

Centralization
Decentralization

storage of patient medical records in a single well record or records of clinic visits for a patient is treated, stored in a place that is part of the medical record.

storage of medical records on each unit of service.

Storage, destruction and confidentiality of medical records in accordance Minister Regulation. 269/MENKES/PER/III/2008. In accordance Permenkes is described among others .:

In management and destruction of medical record,it must meet this following rules :

Medical records of inpatients must be kept for at least 5 years since the last visit of patient or from medical treatment in hospital.
After 5 years,medical records may be destroyed unless the home resume and the medical informed consent. The home resume and the informed consent must be kept within 10 years since it made. Medical records and a home resume kept by officers who appointed by the management of health service facilities.

Medical Records Storage Patient s medical records must be kept for at least 2 years since the last visit of patient or from medical treatment. After 2 years, the medical records may be destroyed. The confidentiality of medical records content : for specific purposes of medical records might be opened with this following provisions:
In the purpose of the patient's health. By court order for law enforcement. Request from the patient Request from the institution / institutions under the legislation. For the purposes of research, audit, education on the condition did not identify the patient.

Ownership of Medical Records

Hospital or health provider Patient public

As responsible for the integrity and continuity of service. As evidence against any attempt at a hospital in the treatment of patients Hospital holds the original medical records

patients have a legal and moral rights for the content of medical records. Patient's medical record have to be kept confidential.

The third party may have (insurance, courts, etc.) All information in medical records are confidential, the exposure of the contents of medical records must be patient consent, unless: legal purposes Referral to other services. Evaluation services in the institution itself Research / education Contract of service agency or organization

Health Care Provider

Right :
Designing the design of medical records Establish rules on medical record Mastering the file of medical records Using the contents of medical records for some specific purposes Wipe out-of-date medical records

Obligation :
Keeping the file well Maintain confidentiality of medical records contents Keeping from damage or loss Reporting the file removal to the Director General of Medical Services Give content to the patient medical records when requested Open contents of medical records to provide law enforcement if the juridical conditions are met.

The patients right

Knowing the content of medical records Contents of medical records kept confidential Using the contents of medical records for various interests, such as to the completeness of insurance claims Give consent or refuse to give consent to other parties who wish to make use of either an individual or institution

Characteristic of medical records data

In Article 53 health legislation explained that patients are entitled to medical secrets. The things that must be kept secret, according to government regulations must keep a secret about medicine includes everything known for doing work in the field of medicine. And everything that is known is that all the facts obtained in the examination, interpretation for diagnosis and treatment.

Noteworthy :
Who able to request the data,: patient Law Enforcement other parties

if the request coming from law enforcement, must be considered criminal procedural law, and if the request coming from the other parties, there must be consent from the patient themselves.
The beneficial interest of the patient Interests of law enforcement The beneficial interest of another party

In terms of the interests of law enforcement, must be considered the procedural law, and if favorable to the interests of other parties must have permission from the patient concerned.

Medical Confidentiality
In criminal, revealing medical confidentiality, punishable violation of Article 322 of the Criminal Code, under penalty of maximum 9 months in prison. In civil cases, patients who feel aggrieved can ask for demand compensation under section 1365 - 1367 Civil Code.

Application
Law no.29/2004, there are provisions dealing with the implementation of the medical record, which is about Service Standards, Measures Agreement, Medical records, Medicine Secrets, quality control and cost Regulation No. 269 health ministers in 2008 on medical records in section 3 states that must be contained within medical records, for example, for patients hospitalized at least contain the identity of the patient, anamnesis, physical examination and medical investigations, diagnosis, management plan, treatment, action, approval medical acts, records of clinical observations, treatment outcome and final resume.

C. Law Punishment A.Medical records as evidence tool Medical record can be use as one of evidence for law enforcement In Article 79 the Medical Practice Act expressly provides that any physician who knowingly makes no medical records can be liable to a maximum confinement of 1 (one) year or a fine of Rp 50.000.000, - (fifty million rupiah).

Legal aspects, Discipline, Ethics and Medical Record Confidentiality

B. Medical Record Confidentiality According to KUHAP, The content can be opened after judge request in front of trial. Doctor responsible for the confidentiality of medicl records and director of health care institution responsible for keeping the medical records.

D. Ethical,discipline punishment Doctors who do not make medical records also may be subject to disciplinary action and conduct in accordance with the Medical Practice Act, Regulations KKI, KODEKI, MKEK. The Medical Council no 16/KKI/PER/VIII/2006 Indonesia of Case Handling Procedures for Alleged Violations and Disciplinary MKDKI MKDKIP

Procedures of medical records(article 5-7, Permenkes No 269/Menkes/Per/III/2008):

Each health care facility that performs outpatient and inpatient services,medical records must be made. Medical records were made by a physician or other health professionals who provide care to patients. Medical records must be made immediately and completely after the patient has received care. Each record on the medical record must bear the name and signature of the person providing the service or action. Rectification of errors in the records of the medical records of the wrong done in writing and initialed by the officers were concerned. Abolition of posts in the medical record by any means is not allowed.

Disclosure of Medical Record Contents

Regulation of the health ministers of the Republic of Indonesia Number 269/MENKES/Per/III/2008 benefits of medical records from the medical records: for the purposes of research, education, and medical audit of all patients do not mention identity

the American Medical Record Association medical information can be opened in :

- Obtain written authorization from the patient

- According to the provisions of law

- Given to other health facilities that are currently treating patients - evaluation of medical treatments - research and education in accordance with local regulations

In the field of criminal disclosure set forth in:

KUHP pasal 112 : disclosure of state secrets
KUHP pasal 322 : related professions

- Any person who knowingly disclose confidential both current and former, punishable by a maximum prison sentence of nine months.
- If the crime is committed against certain people, then it can only be prosecuted on the basis of the complaint.

 Exposure of the contents of medical records for proof of legal cases can be done either by the treating physician without the written permission and consent of the patient. Regulation of health ministers number 269 of 2008 article 11 paragraph 2: "The director of health care facilities may expose the contents of medical records without patient consent under the legislation applicable physician responsible for patient care or hospital administrators to provide copies of medical records in addition to the conclusion

Medical records as evidence in court

The principle of proving negative -> one does not simply expressed as a proven criminal, based on cumulative valid evidence under the law, but also must be accompanied by conviction of the judge.

 Legal function of medical record : as evidence tool.

Confidential and shall maintain the confidentiality.

 According to J Guwandi : 1. Unable to read 2. Any deletion, addition so unable to read 3. Any replacement on the medical records 4. Any change to the number and note 5. Not note What has been done