REKAM MEDIS (MEDICAL RECORD)

In the medical service at the place of practice and standards in hospitals, doctors make a note of the various information about these patients in a file known as Status, Medical Record, Medical Record or Health Record. This file is a file that has significance for patients, doctors, professionals and hospitals kesebatan. In this paper we will discuss about the Medical Record and medikolegalnya aspects.
Medical Record Contents

Contents Medical Record is a state of body and health records, including data about the identity and medical data of a patient. In general, the contents of medical record can be divided into two groups of data are:

1. Medical data or clinical data: What is all the medical data including data on disease history, physical examination, diagnosis, treatment and outcome, report doctors, nurses, lab results, X-ray and so on. These data are data that is confidential (confidential) sebingga pibak not be opened to third party without permission from the patient concerned unless there are other reasons based on rules or laws that force the opening of such information.

2. Sociological data or non-medical data:

That including this data is any other data that are not directly related to medical data, such as identity data, socioeconomic data, etc. address. This data is considered by some to be not a secret, but according to others is also confidential data (confidensial).

Medical Record Implementation

Medical Record Implementation on a health service facility is one indicator of quality of service at the institution. Based on medical record data will be assessed whether the services provided is good enough quality or not, and whether the standard was appropriate or not. For that reason, the government, in this case the Health Department felt the need to adjust the procedures of Medical Record in a ministerial regulation keehatan so obvious signs, that is Permenkes No.749a1Menkes/Per/XII/1989.

Overall management of the Medical Record in Permenkes organized as follows:

I. Medical Record must be created and completed entirely after the patients received services (art. 4). This is so that the recorded data is still original and not a forgotten because of the grace period.

2. Each record Medical Record must be stamped name and signature of health care workers. This is necessary to facilitate the accountability system for the listing of these (article 5).

At the time a patient went to the doctor, actually has happened a therapeutic contractual relationship between patient and physician. Relationship based on trust of patients that physicians are able to treat it, and will keep confidential all confidential patient relationship that is known at the time it occurs.

In these relations a «ara personal data will automatically be many such patients would be known by doctors and health workers who examined the patient. Part of the secret had been made in the form of writing we know as the Medical Record. Thus, the obligation of health professionals to medical confidentiality, including the obligation to maintain the confidentiality of medical record content.

In principle, the contents of medical record belongs to the patient, while the Medical Record file (physically) are owned by hospitals or health institutions. Article 10 Permenkes No. 749a states that the medical record file that is owned health care facilities, which should be stored at least for a period of five years commencing from the date the last patient's treatment. For that purpose in every health institution, established Medical Record Unit in charge of organizing the process of managing and storing medical record at that institution.

Medical Record Benefits
Ministerial Regulation no. 1989 749a states that have Medical Record 5, the benefits are:

1. As a basic health maintenance and treatment of patients
2. As a material proof in a legal case
3. Materials for research purposes
4. As the basic payment and health care costs
5. As a material for preparing health statistics.

In the literature it is said that medical records have five benefits, which for the sake of convenience abbreviated as ALFRED, namely:

1. Adminstratlve value: Medical records is a health care administrative data records.

2. Legal value: Medical records in court evidentiary material dapat.dijadikan

3. Financial value: Medical records can be used as the basis for the breakdown of health care costs to be paid by the patient

4. Value Research: Medical Record Data can be used as material for research in the field of medicine, nursing and health.

5. Education value: The data in the medical record can be educational materials and teaching medical students, nursing and other health professionals.

Medical Record Storage
In the medical audit, generally the source of data used medical records of patients, either outpatient or inpatient care. Medical record is the best source of data on hospital, although many have weaknesses. Some shortcomings of medical records is often the absence of some data that socio-economic character of patients, often charging an incomplete medical record, not tercantumnya perceptions of patients, does not contain a treatment of "complementary" as an explanation of doctors and nurses, often does not contain inpatient visits post-treatment control , etc..

Impact of medical audit is of course expected to improve the quality and effectiveness of medical services at health facilities. But in addition, we also need memperhatikan effects, such as the impact terhadap perilaku the professional, management responsibilities against the value of medical audit tersebut, how far mempengaruhi workload, rasa accountability, career prospects and morals, and the type of training required.

Among all the benefits of Medical Record, which is the most important legal aspects of Medical Records. In the case of medical malpractice, nursing and pharmacy, medical record is one of the important written evidence. Based on the information in the medical record, legal officers and judges can determine whether or not there has been malpractice suits, how the occurrence of such malpractices and to determine who exactly is to blame for the case.