Ownership of Medical Records in Indonesia: Discourse on Legal Certainty and Justice
Abstract
Medical disputes between patients and health workers place medical records as a vital document for evidentiary in a court proceeding. The existing law and regulations in Indonesia determine that the medical record file is owned by the health service facility, while the patient receives a summary of the medical record. This study aims to analyze medical record ownership in Indonesia from perspectives of legal certainty and justice. This article reflects normative juridical research that explores relevant primary and secondary legal materials to be analyzed deductively. This article concluded that the obligation of health workers to make medical records in proving that they have delivered properly a health service as stipulated in the law and regulations reflects a legal certainty. However, laws and regulations governing the ownership of medical records seem not to fully reflect the principle of justice since medical record files are owned by doctors, dentists, or health service facilities. Even though patients/health service recipients are entitled to requesting the files from health care facilities, the sense of justice for the patients would be in the form of easy procedures for obtaining medical records.
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References
Manan, Bagir. Hukum Positif Indonesia: Suatu Kajian Teoritik. Yogyakarta: FH UII Press, 2004.
Mustafa, Bachsan. Integrated Indonesian Legal System, II. Bandung: Citra Aditya Bakti, 2016.
Marzuki, Peter Mahmud. Pengantar Ilmu Hukum (Edisi Revisi). Jakarta: Pernada Media Grup, 2012.
Journal Article
Abduh, Rachmad. “Kajian Hukum Rekam Medis Sebagai Alat Bukti Malapraktik Medis.” De Lega Lata 6, no. 1 (2020): 221-234. https://doi.org/10.30596/delegalata.v6i1.4661.
Aristya, Sandra Dini Febri. “Pembuktian Perdata Dalam Kasus Malpraktik Di Yogyakarta.” Mimbar Hukum, Special edition (2011): 180–205. https://doi.org/https://doi.org/10.22146/jmh.16166.
Butler, Jorie M., et al. “Clinician Documentation of Patient Centered Care in the Electronic Health Record.” BMC Medical Informatics and Decision Making 22, no. 1 (2022): 1–12. https://doi.org/10.1186/s12911-022-01794-w.
Cohen, Jonathan and Tamar Ezer. “Human Rights in Patient Care: A Theoretical and Practical Framework.” Health and Human Rights 15, no.2 (2013): 7-19.
Eddyono, Luthfi Widagdo. “The Constitutional Court and Consolidation of Democracy in Indonesia.” Jurnal Konstitusi 15, no. 1 (2018): 1-26. https://doi.org/10.31078/jk1511.
Hage, Markus Y. and Panggih Kusuma Ningrum. “Corrective Justice and Its Significance on the Private Law”. Journal of Indonesian Legal Studies 7, no. 1 (2022): 1-30. https://doi.org/10.15294/jils.v7i1.46691.
Fadhillah, Harif, Endang Wahyati, and Budi Sarwo. “Pengaturan Tentang Tenaga Kesehatan Dalam Peraturan Perundang-Undangan Dan Azas Kepastian Hukum.” Soepra Jurnal Hukum Kesehatan 5, no. 1 (2019): 146–162. https://doi.org/10.24167/shk.v5i1.1653.
Febriansyah, Ferry Irawan. “Keadilan Berdasarkan Pancasila Sebagai Dasar Filosofis Dan Ideologis Bangsa.” DiH Jurnal Ilmu Hukum 13, no. 25 (2017): 1–27. https://doi.org/https://doi.org/10.30996/dih.v13i25.1545.
Heryanto, Bambang. “Malpraktik Dokter Dalam Perspektif Hukum.” Jurnal Dinamika Hukum 10, no. 2 (2010): 183–191. https://doi.org/10.20884/1.jdh.2010.10.2.151.
Huxtable, Richard and Giles Birchley. “Seeking Certainty? Judicial Approaches To The (Non-) Treatment of Minimally Conscious Patients.” Medical Law Review 25, no. 3 (2017): 428–455. https://doi.org/10.1093/medlaw/fwx014.
Irmawati, I., Danuri, A., Sudiyono, S., & Rahmawati, F. Analisis Kuantitatif Rekam Medis Pasien Rawat Inap di Bangsal Mawar RSUD Ungaran. Jurnal Rekam Medis dan Informasi Kesehatan 1, no. 1 (2018): 11-15. https://doi.org/10.31983/jrmik.v1i1.3574.
Nasution, B. J. “Kajian Filosofis Tentang Konsep Keadilan Dari Pemikiran Klasik Sampai Pemikiran Modern.” Yustisia Jurnal Hukum 3, no. 2 (2014). https://doi.org/10.20961/yustisia.v3i2.11106.
Nurhaidah, Thontowi Djauhari and Tatong Harijanto. “Faktor-Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Inap di Rumah Sakit Universitas Muhammadiyah Malang.” Jurnal Kedokteran Brawijaya 29, no. 3 (2016): 258–264. https://doi.org/10.21776/ub.jkb.2016.029.03.4.
Ramadianto, Anggra Yudha. “Aspek Filosofis Moral Dan Hukum Kewajiban Menyimpan Rahasia Medis Pasien Sebagai Objek Perikatan (Prestasi) Dalam Kontrak Terapeutik.” Simbur Cahaya 22, no. 3 (2017): 4905-4920. http://dx.doi.org/10.28946/sc.v24i3%20Sep%202017.82
Selvia Juwita Swari, et.al. “Analisis Kelengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap RSUP Dr. Kariadi Semarang.” Arteri : Jurnal Ilmu Kesehatan 1, no. 1 (2019): 50–56. https://doi.org/10.37148/arteri.v1i1.20.
Sinaga, Rudiansyah Putra. “The Urgency of Legal Policy to Fulfill The Constitutional Rights to Employment Social Security for Vulnerable Workers in The National Social Security System.” Jurnal Hukumtora: Hukum Untuk Mengatur Dan Melindungi Masyarakat 7, no. 3 (2021): 476–94. https://doi.org/https://doi.org/10.55809/tora.v7i3.51.
Palabindala, Venkataraman, Amaleswari Pamarthy, and Nageshwar Reddy Jonnalagadda. “Adoption of Electronic Health Records and Barriers.” Journal of Community Hospital Internal Medicine Perspectives 6, no. 5 (2016): 1-3. https://doi.org/10.3402/jchimp.v6.32643.
Pratt, B., Wild, V., Barasa, E., Kamuya, D., Gilson, L., Hendl, T., & Molyneux, S. “Justice: A Key Consideration in Health Policy and Systems Research Ethics.” BMJ Global Health 5, no. 4 (2020): 1-11. https://doi.org/10.1136/bmjgh-2019-001942.
Syaufi, Ahmad, Diana Haiti, and Mursidah. “Application of Restorative Justice Values in Settling Medical Malpractice Cases.” International Journal of Criminology and Sociology 10, (2021): 103-110. https://doi.org/10.6000/1929-4409.2021.10.14.
Williams, Brent A., et al. “Establishing a National Cardiovascular Disease Surveillance System in the United States Using Electronic Health Record Data: Key Strengths and Limitations.” Journal of the American Heart Association 11, no. 8 (2022): 1–14. https://doi.org/10.1161/jaha.121.024409.
Wiraja, M. K. M and Ni Made Umi Kartika Dewi. “Analisis Ketidaklengkapan Rekam Medis Pasien Rawat Inap di Rumah Sakit Dharma Kerti Tabanan.” Jurnal Administrasi Rumah Sakit 6, no. 1 (2019): 11-20. http://dx.doi.org/10.7454/arsi.v6i1.3553.
Wicaksono, Raden Mas Try Ananto Djoko. “Reviewing Legal Justice, Certainty, and Legal Expediency in Government Regulation Number 24 of 2018 Concerning Electronically Integrated Business Services.” Lex Scientia Law Review 5, no. 1 (2021): 1-24. https://doi.org/10.15294/lesrev.v5i 1.44905.
Wu, Yuju, et.al. “Using Standardised Patients to Assess the Quality of Medical Records: an application and evidence from rural China.” BMJ Quality & Safety 29, no. 6 (2020): 491-498. https://dx.doi.org/10.1136/bmjqs-2019-009890.
Velthoven, Michelle Helena van, et.al. “Feasibility of Extracting Data from Electronic Medical Records For Research: An International Comparative Study.” BMC Medical Informatics and Decision Making 16, no. 1 (2016): 1-10. https://doi.org/10.1186/s12911-016-0332-1.
Legal Documents
Indonesia. The 1945 Constitution of the Republic of Indonesia.
Indonesia. Law No. 29 of 2004 concerning Medical Practice.
Indonesia. Law No. 11 of 2008 concerning Information and Electronic Transactions.
Indonesia. Law No. 36 of 2009 concerning Health.
Indonesia. Law No. 36 of 2014 concerning Health Workers.
Indonesia. Law No. 38 of 2014 concerning Nursing.
Indonesia. Law No. 4 of 2019 concerning Midwifery.
Indonesia. Regulation of Minister of Health No. 269/MENKES/PER/III/2008 concerning Medical Record.
Indonesia. Regulation of Minister of Health No. 55 of 2013 concerning the Implementation of Medical Recorder Work.
Indonesia. Regulation of Minister of Health No. 4 of 2019 concerning Technical Standards for the Fulfilment of Basic Services Quality in Minimal Service Standards in Health Sector.
Indonesia. Regulation of Minister of Health No. 20 of 2019 concerning the Implementation of Telemedicine Services between Health Service Facilities in Indonesia.
Indonesia. Decree of Minister of Health No. HK.01.07/MENKES/312/2020 concerning Professional Standards for Medical Recorders and Health Information.
Indonesia. Decree of Minister of Health No HK.01.07/MENKES/425/2020 concerning Nurse Professional Standard.
Indonesia. Circular Letter of Minister of Health No. HK.02.01/MENKES/303/2020 concerning the Implementation of Health Services through the Utilization of Information and Communication Technology to Prevent the Spreading of Corona Virus 2019 Disease.
Indonesia. Regulation of Indonesian Medical Council No. 74 of 2020 concerning the Clinical Authority and Medical Practice through Telemedicine during the Corona Virus 2019 (COVID-19) Pandemic in Indonesia.
Other Documents
Committee on Economic, Social, and Cultural Rights, General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 12) Adopted at the Twenty-second Session of the Committee on Economic, Social and Cultural Rights, on 11 August 2000 (Contained in Document E/C.12/2000/4).
Indonesian Medical Council, Medical Record Manual, 2016.
World Health Organization. “Basic documents: forty-ninth edition” (including amendments adopted up to 31 May 2019). Geneva: World Health Organization; 2020.
World Health Organization. Division of Epidemiological Surveillance and Health Situation and Trend Assessment. “Guidelines for medical record practice.” World Health Organization, 1980.
World Health Organization. “Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care.” Geneva: World Health Organization, 2021.
World Health Organization. “Medical Records Manual: A Guide for Developing Countries, revised and updated version. Manila: Western Pacific Region, 2006.
Case Law
Indonesia. Decision of the Constitutional Court No. 82/PUU-XIII/2015 (Judicial Review on Law No. 36 of 2014 concerning Health Workers)
Indonesia. Decision of the Supreme Court No . 21P/HUM/2011 (Judicial Review on Regulation of Minister of Health No. 269 /Menkes/III/2008 concerning Medical Records)
Website Content
Bernstein, Jack, Injury Attorneys. “Is Medical Malpractice a Civil Case or a Criminal Case?”. 2021. https://bernsteininjurylaw.com/blog/medical-malpractice-civil-case-vs-criminal-case/
Hadi, Abdul. “Dokter Malpraktik Elisabeth Divonis Bebas, Korban Laporkan Hakim ke KY.”. 2020. https://www.antvklik.com/headline/dokter-malpraktik-elisabeth-divonis-bebas-korban-laporkan-hakim-ke-ky
Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada. “Dinamika Sengketa Medis di Indonesia.” 2021. https://fkkmk.ugm.ac.id/dinamika-sengketa-medis-di-indonesia/
Kerr, Gaven. “Aquinas: Metaphysics.” https://iep.utm.edu/aq-meta/
Judicial Commission of the Republic of Indonesia, Eka Putra and Festy. “Penegakan Hukum Wujudkan Keadilan, Kepastian, dan Kemanfaatan Hukum.” 2017. https://www.komisiyudisial.go.id/frontend/news_detail/514/penegakan-hukum-wujudkan-keadilan-kepastian-dan-kemanfaatan-hukum
Safa’at, Muchamad Ali. “Pemikiran Keadilan (Plato, Aristoteles, John Rawls).”
http://www.safaat.lecture.ub.ac.id/files/2011/12/keadilan.pdf
Public Relations Universitas Gadjah Mada/Agung. “Konflik Dokter dan Pasien Wajib Gunakan Mediasi.” 2015. https://ugm.ac.id/id/berita/10262-konflik-dokter-dan-pasien-wajib-gunakan-mediasi
Indonesian Association of Medical Record Professionals and Health Information. “Sejarah Pormiki.” https://pormiki.or.id/sejarah-terbentuknya-pormiki/
VOI. “Cegah Malpraktik, Pelanggaran Etik Pasien dan Dokter, KSP Sebut Pemerintah Siapkan Payung Hukum Bagi Telemedisin.” 2022. https://voi.id/berita/134483/cegah-malpraktik-pelanggaran-etik-pasien-dan-dokter-ksp-sebut-pemerintah-siapkan-payung-hukum-bagi-telemedisin