Legal Consistency of Health Personnel in Making Medical Records
DOI:
https://doi.org/10.26555/novelty.v13i2.a23592Keywords:
Medical Records, Documentation of care, Doctors, Nurses, Midwives,Abstract
Introduction to The Problem: Medical record is a record or document containing patient identity, examination, treatment, action and other services that must be made by health workers, but not 100% complete medical records. Currently, when talking about medical records, doctors always think, while in the law on health workers, medical records must be made by health workers
Purpose/Objective Study: to find out the legal certainty of health workers in making medical records
Design/Methodology/Approach: This research is normative with deductive research analysis.
Findings: the results of patient records carried out by the medical profession are called medical records, patient records carried out by nurses are called nursing care documentation and patient records carried out by midwives are called midwifery care documentation. Doctors who do not make medical records can get criminal sanctions, while nurses and midwives if they do not do documentation of care will get administrative sanctions.
Paper Type: Research Article
References
Anita, W. (2018). The implementation of documentation by midwives in Pekanbaru. Kesmas, 13(1), 43–47. https://doi.org/10.21109/kesmas.v13i1.1403
Ar, S. (2009). Penentuan Sanksi Pidana dalam Suatu Undang-Undang. Legislasi Indonesia, 6, 846. https://e-jurnal.peraturan.go.id/index.php/jli/article/view/337/221
Asadinejad, S. M. (2022). The Relationship between Patients Informed Satisfaction and Medical Ethics from an Iranian Legal Perspective Review article The Relationship between Patients Informed Satisfaction and Medical Ethics from an Iranian Legal Perspective. Pravara Med Rev, 14(3), 59–69. https://doi.org/10.36848/PMR/2022/70100.510250
Bailey, S. G. W. W. Y. (2015). What factors affect documentation by midwives? A prospective study assessing relationship between length of shift, workload, and quality of note keeping. 31(8), 787–792. https://www.sciencedirect.com/science/article/abs/pii/S0266613815001163#:~:text=The basic note keeping and partogram documentation were,shifts may help improve the quality of documentation.
Butler, J. M., Gibson, B., Patterson, O. V, Damschroder, L. J.,
Halls, C. H., Denhalter, D. W., Samore, M. H., Li, H., Zhang, Y., & Duvall, S. L. (2022). Clinician documentation of patient centered care in the electronic health record. BMC Medical Informatics and Decision Making, 22(1), 1–12. https://doi.org/10.1186/s12911-022-01794-w
De Groot, K., Douma, J., Paans, W., & Francke, A. L. (2022). Patient participation in electronic nursing documentation: An interview study among home-care patients. Health Expectations, 25(4), 1508–1516. https://doi.org/10.1111/hex.13492
Edytya, N. P., & Prawira, R. S. (2019). Kenyataan Penegakan Hukum di Indonesia dalam Perspektif Hukum dan Pembangunan: Hukum Harus Ditaati atau Ditakuti? Lex Scientia Law Review, 3(2), 177–190. https://doi.org/10.15294/lesrev.v3i2.35399
Ekawati, M. E., Laksono, I. S., & Sanjaya, G. Y. (2013). Rekam Medis Eletronik Tidak Menjamin Kelengkapan Dokumentasi Kesehatan Pasien [Udinus]. http://eprints.dinus.ac.id/2079/
Ghafur, A. & Olfah, Y. (2016). Dokumentasi Keperawatan. In Pusdik SDM Kesehatan. Kementrian Kesehatan Republik Indonesia.
Nasution, M. H. B., Wahyuni, S., Lubis, Y. E. P., & Nasution, A. N. (2022). Analysis Of Inpatient Medical Record Management Based On Medical Record Service Standards At Government Hospitals In Medan. International Journal of Health and Pharmaceutical (IJHP), 2(4), 692–702. https://doi.org/10.51601/ijhp.v2i4.153
Maharani, W., & Setyowati, M. (2015). TINJAUAN FAKTOR PENYEBAB KETIDAKLENGKAPAN DOKUMEN REKAM MEDIS RAWAT JALAN DI BALAI KESEHATAN PARU MASYARAKAT (BKPM) SEMARANG TAHUN 2015 Wahyatunnisa (Vol. 19). http://eprints.dinus.ac.id/17407/1/jurnal_16216.pdf
Hidayat, T., Turgandi, A., Anita, D., Amalia, A., Karmila, M., Sufriandi, Y., & Amelia, C. C. (2022). Filling in informed consent in the c-section operations section of Subang Regional General Hospital. International journal of health sciences, 6(3), 1511–1519. https://doi.org/10.53730/ijhs.v6n3.13144
Irmawati, I., Danuri, A., Sudiyono, S., & Rahmawati, F. (2018). Quantitative Analysis of Medical Records of Inpatients in Ward Mawar Ungaran Hospital. Jurnal Rekam Medis dan Informasi Kesehatan, 1(1), 11. https://doi.org/10.31983/jrmik.v1i1.3574
Mahkamah Agung. (2010). Putusan nomor 134K/PID.SUS/2010. Mahkamah Agung Republik Indonesia.
Mahkamah Agung. (2012). Nomor: 281/Pdt.G/2012/PN.Bdg “Demi Keadilan Berdasarkan Ketuhanan Yang Maha Esa.” Mahkamah Agung Republik Indonesia. https://putusan3.mahkamahagung.go.id/direktori/putusan/d36e4d0d0a7b554f4c597617288e524e.html
Mahkamah Agung. (2021). Putusan Nomor 233K/Pid.Sus/2021. Mahkamah Agung Republik Indonesia.
Nakate, G. M., Diane, D., Pammla, P., Karen, B. D., & Ruby, D. (2015). The Nursing Documentation Dilemma in Uganda: Neglected but Necessary. A Case Study at Mulago National Referral Hospital. Open Journal of Nursing, 05(12), 1063–1071. https://doi.org/10.4236/ojn.2015.512113
Nurhaidah, Tatong Harijanto, T. D. (2016). Factors Causing Incomplete Completion of Inpatient Medical Records in Hospitals. 29(3), 258–264. http://jkb.ub.ac.id/index.php/jkb/article/view/1642
Oktavira, B. A. (2022). Inti Sari Perbedaan Hukum Pidanan dan Perdata. Hukum Online. https://www.hukumonline.com/klinik/a/intisari-perbedaan-hukum-pidana-dan-perdata-lt57f2f9bce942f/
Organization Commission On Accreditation Of Health Care. (2021). Hospital Accreditation Standards. https://www.hcca-info.org/. https://www.hcca-info.org/
Purwanti, E. D. (2012). Kelengkapan Dokumentasi Asuhan Keperawatan dan Karakteristiknya Pada Pasien Rawat Inap Dewasa Non Kebidanan Di Rumah Sakit Haji Jakarta. https://lib.ui.ac.id/file?file=digital/20319949-S-PDF-Eka Desi Purwanti.pdf
Ranjbar, K., Sabetsarvestani, R., Oghlaee, H., Sarvestani, P. S., Dehghan, A., & Shirazi, Z. H. (2021). Using Electronic Software for Nursing Documentation in Nursing Students. Florence Nightingale Journal of Nursing, 29(2), 128–136. https://doi.org/10.5152/fnjn.2021.20077
Reza, S., Faride, K., Zahra, A., Marjan, G., Roya, S., Niloofar, M., & Roya, A. (2011). The Study of Accountability Rate of Medical Records in Referral Cases to Forensic Medicine 2000. Scientific Journal Of Forensic Medicine, 17(1), 29–35. Https://Www.Sid.Ir/Paper/53386/En#Downloadbottom
Said, N. (2016). Hubungan Hukum Antara Pasien Dan Tenaga Medis Serta Rumah Sakit (Vol. 693). https://www.neliti.com/publications/152891/hubungan-hukum-antara-pasien-dan-tenaga-medis-serta-rumah-sakit
Shidarta; Lakonawa, P. (2018). Lex Specialis Derogat Legi Generali: Makna Dan Penggunaannya. Binus University Busines Law. https://business-law.binus.ac.id/2018/03/03/lex-specialis-derogat-legi-generali/
Sjamsuhidajat, S. A. (2006). Manual Rekam Medis. In Konsil Kedokteran Indonesia. Konsil Kedokteran Indonesia. http://www.kki.go.id/assets/data/menu/Manual_Rekam_Medis.pdf
Sugiarsi, S., & Rohmadi. (2020). Literature Review: Why Incomplete Medical Records? Indonesian of Health Information Management Journal, 8(2), 45–52. https://inohim.esaunggul.ac.id/index.php/INO/article/view/212
Sulardi, Y. P. W. (2015). Legal Certainty, Purposiveness, and Justice in the Juvenile Crime Case. Jurnal Yudisial, 8 no 3, 251–268.
Supriyadi. (2015). Penetapan Tindak Pidana Sebagai Kejahatan Dan. Mimbar Hukum, 27(3), 389–403. https://doi.org/https://doi.org/10.22146/jmh.15878
Supriyatin, U. (2018). Legal Relations Between Patients and Medical Personnel (Doctors) In Health Services. Jurnal Ilmiah Galuh Justisi, 6(2), 184. https://doi.org/10.25157/jigj.v6i2.1713
Swari, S. J., Alfiansyah, G., Wijayanti, R. A., & Kurniawati, R. D. (2019). Analysis of Completeness of Completion of Medical Record Files for Inpatients Dr. RSUP. Kariadi Semarang. ARTERI : Jurnal Ilmu Kesehatan, 1(1), 50–56. https://doi.org/10.37148/arteri.v1i1.20
