Harmonization of Regulations Related to the Medical Record Retention Period (Paper-Based & Electronic-Based)

Abstract

--Medical record is a file that contains records and documents about patient identity, examination, treatment, actions, other services that have been provided to patients. Health service facilities are required to provide the necessary facilities in the context of organizing medical records, from patients coming to patients returning and continuing with data processing, reporting, including storage and maintenance (retention) of medical records. Whatever type and model of medical record is developed, WHO states that determining retention periods is a matter that must be considered to meet legal, medical, management, education, research, and so on, in accordance with the regulations in force in the country concerned. The selection and determination of which data will be retained and for how long is a critical step to think about. The retention period for medical records has been regulated in several regulations, including laws, government regulations, regulations of the minister of health, circular of director general of Yanmed, and so on. The regulation of retention of medical records has not been harmonized so far both for the length of the retention period and the types of data retention, both for paper-based and electronic-based medical records. This condition has the potential to cause legal problems because the medical record is a document that is regulated by law for its manufacture, use and management. This study aims to identify various regulations that exist and apply to date related to the regulation of medical record retention. The study was conducted by searching the document and analyzing the document content. From the results of this study it can be concluded that various existing and current regulations relating to retention of medical records have not shown harmony in the regulation of medical record retention periods or types of data retention. This happens both for paper-based and electronic-based medical records. Harmonization and reconstruction steps are needed to clarify and reinforce regulations related to medical record retention.