Legal Protection of Patient Rights to Completeness and Confidentiality in Management of Medical Record Documents

Sugiarti, Ida Legal Protection of Patient Rights to Completeness and Confidentiality in Management of Medical Record Documents. HEALTH SCIENCE INTERNATIONAL CONFERENCE. BAKTI TUNAS HUSADA. 2ND 2019. (BTH-HSCI 2019) HEALTH SCIENCE RESEARCH AND HEALTH WORKFORCE EMPOWERMENT TO FACE INDUSTRY.

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Official URL: https://www.proceedings.com/content/055/055706webt...

Abstract

Various problems of the lawsuit exist because the health service is not optimal, complaints about the quality of health services are also perceived. If the medical record document is filled with complete, it will be easy for health professionals to explain it if there is a lawsuit. The contents of the medical record contain medical secrets. Completeness and confidentiality are the rights of the patient and are protected by law. The purpose of this study was to understand the implementation of the arrangement of the patient's right for the confidentiality and completeness of medical record fulfillment filling and legal consequences of that. The method used a sociological juridical, the approach is analytical descriptive. The type of data is primary and secondary data. Collection of information through literature and interviews. Data analysis used a qualitative approach with thematic analysis and juridical analysis. The result is shown in the fulfillment of the right of patients for the completeness of medical record filling already contained in the legislation and poured into Standard Operating Procedures (SPO), but not implemented according to Minimum Service Standards. Confidentiality is also contained in the SPO. The existing legislation as a reference for the manufacture of SPO of the medical record is not yet complete, so the SPO is not yet complete such as the confidentiality regulation for the use of electronic medical records. The completeness definition of the medical record is not clear also, the regulatory about what needs to be revised. The confidentiality and completeness of the medical record document bring the legal effect because of not fulfilling the promise as agreed in the form of optimal service endeavors. The existing regulations necessary to revised as a form of protection of the patient's rights, with due observance of the daily implementation to fulfill the public sense of justice

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