MEDICAL RECORDS

Created By :
Lowrenszya Siagian (8111416198)
 CONTENTS
1. LEGAL BASIS
2. DEFINITON
3. CONTENTS OF MEDICAL RECORDS
4. PROCEDURES OF MEDICAL RECORDS
5. STORAGE, DESTRUCTION & CONFIDENTIAL MEDICAL RECORDS
6. OWNERSHIP, RESPONSIBILITY AND UTILIZATION
7. EXAMPLE OF CASE
8. CONTOH KASUS
LEGAL BASIS
 DEFINITION OF MEDICAL RECORDS

 According to Article 1 point (1) of PERMENKES 296/2008

Medical records is a file containing records and documents including the identity of
the patient, the results of the examination, the treatment that has been given, and
other actions and services that have been given to the patient.
According to Article 46 paragraph (1) of Law Number 29 of 2004 concerning
Medical Practice
States that every doctor or dentist in carrying out medical practice must make a
medical record. The meaning of the medical record itself according to the
explanation of Article 46 paragraph (1) of the Medical Practice Law is a file
containing notes and documents about the patient's identity, examination,
treatment, actions, and other services that have been given to the patient.
 CONTENTS OF MEDICAL RECORDS

 Outpatient  Data on outpatients included in medical records at least include:

1. Patient identity
2. Date and time
3. Anamnesis
4. Results of physical examination and medical support
5. Diagnosis
6. Treatment planning
7. Treatment and / or other actions that have been given to the patient
8. For patients with dental cases complete with odontogram clinics
9. Approval of actions if necessary
 CONTENTS OF MEDICAL RECORDS

 Inpatients  Data on inpatients included in medical records at least include:

1. Patient identity
2. Date and time
3. Anamnesis
4. Results of physical examination and medical support
5. Diagnosis
6. Treatment planning
7. Treatment and / or other actions that have been given to the patient
8. Approval of actions if necessary
9. Records of clinical observations and treatment outcomes
 CONTENTS OF MEDICAL RECORDS

 Emergency patients Data on emergency patients included in medical records at least include:
1. Patient identity
2. Conditions when a patient arrives in a health care facility
3. Identity of person who accompanied/responsible for the patients
4. Date and time
5. Anamnesis
6. Results of physical examination and medical support
7. Diagnosis
8. Treatment and / or action
9. Summary of the condition of the patient before leaving emergency department services and follow-up plans
10. Names and signatures of doctors, dentists, or certain health personnel who provide health services
11. Transportation facilities used for patients who will be transferred to other health care facilities
12. Other services that have been given to patients
  PROCEDURES FOR PERFORMING
MEDICAL RECORDS

Every doctor and dentist must make a medical record, as soon as the patient receives services
Making medical records is carried out through recording and documenting the results of
examinations, treatments, services, and other actions that have been given to patients
Recording must be given a name, time, signature of a doctor, dentist, or certain health
personnel who provide health services directly.
 In article 46 of Law No. 29 of 2004 about the medical practice states that "every medical
record must be affixed with the name, time and signature of the officer who provides services
or actions".
If there is a recording error, repairs can be made by crossing out directly, without removing
the affixed notes and affixing initials. Doctors / dentists or certain health personnel are
responsible for the records of the documents they make.
  STORAGE, DESTRUCTION & CONFIDENTIALITY
OF
MEDICAL RECORDS

1. Storage
The life of medical records of inpatients in hospital facilities is 5
years from the last date the patient received treatment, after the 5-
year time limit has been exceeded, unless it’s the summary of medical
records of patient that goes home and the approval of medical action
can be stored within 10 years.
While the life of health facilities other than hospitals is 2 (two)
years after the deadline, the medical record can be destroyed by
following the rules set for the destruction of documents.
  STORAGE, DESTRUCTION & CONFIDENTIALITY
OF
MEDICAL RECORDS

2. Retention and Destruction

Retention or shrinkage of Medical Record Data  an activity
that separates between medical record documents that are still
active with non-active medical record.
 Active Medical Record : documents that are still active are used
for patient care
 Inactive Medical Record : documents that are no longer used for
patient care
  STORAGE, DESTRUCTION & CONFIDENTIALITY
OF
MEDICAL RECORDS

3. Confidentitality
Information about diagnosis, history of the disease, examination history, history of
treatment of patients must be kept confidential by doctors, dentists, certain health
workers, management officers and the head of health service facilities.
Accroding to Article 10 of PERMENKES No. 69/2008, The information of the medical
records can be opened :
1) For the sake of the health of the patients
2) Meet the demands of law enforcement officials in order to enforce a court order
3) Demand or consent of the patient himself
4) Request from the institution / agency under the provisions of law
5) For the purposes of research, education, and medical audit, as long as no mention of the identity of
the patient
 The Medical Record request for this purpose must be made writtenly to the head of
the health service facility
  OWNERSHIP, RESPONSIBILITY & UTILIZATION
OF
MEDICAL RECORDS

 Ownership of Medical Records

 The medical record file belongs to the health service facility while the contents of the
medical record belong to the patient.
 If the patient asks for the contents of the record, it can be given in the form of a medical
record summary or a summary of going home.
 A summary of the medical record can be given, recorded by the patient or the person
authorized or with written consent of the patient or the family of the patient who is
entitled to it.
 Responsibility
The head of the health service facility is the one responsible for loss, damage, forgery,
and / or use by persons or entities that are not entitled to medical records.
  OWNERSHIP, RESPONSIBILITY & UTILIZATION
OF
MEDICAL RECORDS

 Utilizations of Medical Records, can be used as:

1. Health care and treatment of patients
2. Evidence in the law enforcement process
3. Education and research needs
4. Basic payment of health implementation costs
5. Health statistics
 EXAMPLE OF MEDICAL RECORD CASE

1 3
 The Jakarta Legal Aid Institute
(LBH) reported the RSCM because it
was considered to have harmed
patients named Lina Ismalawati (24).
This is related to not giving a medical
record from a patient named Lina
Ismalawati, where we have requested
the medical record by writing twice,
but there is no response, and the
patient has written to the Director of
RSCM, but also has no response.
 Arriving at the Urology section
of RSCM, his wife was referred
2 to neurology. From neurology to 4
According to the statement of emergency room. In the
the patient's husband, Cecep Surya emergency room. The next day  At that time, the team of
Lesmana, this case began when she was told to take a rapid HIV doctors proposed that Lina
Lina wanted to take off her urine test, when a rapid HIV test was can have another HIV test be
hose after 3 weeks of being treated carried out, it turned out that the carried out, because this test
at home. Previously, Lisna had doctor diagnosed that Lina was was more accurate than the
treatment in Cibinong General HIV positive. Seeing the Rapid HIV test. After the
Hospital and was diagnosed with irregularities in the diagnosis, examination, it turned out
lung spots. Because she felt she Cecep volunteered to carry out a that the results of the Lina
had improved, the family then rapid screening HIV test, his HIV test showed that the
decided to take off her urine hose result was negative. patient did not have HIV.
at the RSCM.
EXAMPLE OF MEDICAL RECORD CASE
5 6
 They asked for the medical
record when the patient was
diagnosed as HIV positive but
was not given by the RSCM.
When diagnosed with HIV
negative medical records were
given, but when diagnosed
with HIV positive it was not
given.
 Maruli added, the
diagnostic errors made by the
RSCM doctor team had fatal
consequences for patients, who
suffered a large wound with a
diameter of approximately 10
cm right at the back of the
waist and had to do vascular
surgery, causing the patient to
lose consciousness.
 ANALYZE ABOUT THE CASE
1. According to Article 12
PERMENKES No. 269 year
2008 about Medical Records :
 Referring to paragraph (1) and
(2), the medical record file
belongs to the health service
facility while the contents of the
medical record belong to the
patient.
 Referring to paragraph
(3), it is clearly stated that
what is meant by the
contents of medical
records that can be owned
by patients is in the form
of summaries of the
contents of medical
2. According to Article 48 Law
No. 29 year 2004 about
Medical Practices :
 The secret of medical can
be opened only for the
benefit of the patient's
health, meets the demands
of law enforcement
officials in the context of
law enforcement, patient's
own request, or based on
statutory provisions.
3. According to Article 10
paragraph 2 PERMENKES
No. 269 year 2008 about
Medical Records :
 One of the reason, the
information on medical
records can be opened for
the sake of the health of
the patients.
 Set of records regarding Permenkes
disease history & 585/1989
Formal treatment history UU No. 29/2004
Praktik Kedokteran
Patient
Meaning
Patient identity
Disease record Product
Result of Material relationship 1. Informed
communi Medical Result of further
between Consent
cation Records examination 2. Medical records
doctor &
patient

Doctor Function •Administration

•Legal
Permenkes •Financial
268/2008 •Research
UU No. 29/2004 •Education
Praktik Kedokteran •Documentation
THANK
YOU
Complaining about hospital services that are not in accordance
with the standard of service through print and electronic media in
accordance with the provisions of legislation (see Article 32 letter
r), the patient and is considered to have released the confidential
rights of his medical to the public (Article 44 paragraph 2).
Information to the media will then lead to the authority of the
Hospital to disclose the patient's medical secrets as the right to
answer the Hospital because the hospital will certainly protect
the prestige of their hospital (see Article 44 paragraph [3]).
the purpose of retention in advance is to reduce the storage burden and
prepare activities for assessing value for medical records to then be kept
or destroyed. so there is retention of the medical record data active and
inactive first. while the process is preceded by a retention schedule of
the medical record and the making of the Minutes of Extermination.
while the destruction was carried out based on Government Regulation
Number 34 of 1979 about Archive Shrinkage stated that the process
archive destruction must be done in total by burning, chopping or
recycling so that it can no longer be known for its contents and the shape
Article 44 of hospital law said that the Hospital is legally responsible for all losses incurred
due to negligence performed by health workers at the hospital.
And if the hospital is proven to open information to the public then under Article 58 of the
Health Law, hospitals can be prosecuted for compensation due to errors or omissions in
their health services including the leak of medical secrets.

In administrative, hospital and health personnel legal responsibilities that are proven to
have leaked information will be given administrative sanctions, in the form of revocation of
licenses or verbal and written warnings.
For the responsibility of criminal law, the provisions of Article 322 of the Criminal Code
state that anyone who deliberately opens a secret that must be kept due to his position will
be subject to a jail sentence no later than nine months or a fine
UU PRAKTIK KEDOKTERAN : UU NO 29 TAHUN 2004
UU RUMAH SAKIT : UU NO 44 TAHUN 2009
UU KESEHATAN : UU NO 36 TAHUN 2009