Electronic Medical Records as Evidence of Therapeutic Transactions

Jurnal Dinamika Hukum Pub Date : 2021-09-28 DOI:10.20884/1.jdh.2021.21.3.3520

P. M. Putri, Y. Saefudin

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Abstract

The results of the medical examination are proof of the doctor-patient relationship, which is documented in a record containing an explanation of the patient's health condition based on the results of the examination that has been carried out. Although the recording process is an obligation, there are several cases where medical records are not filled in correctly and some are not even filled in by officers. Therefore, this research is designed to find out the urgency of electronic medical records as evidence of therapeutic transactions. The problems studied in this article are: First, the juridical consequences of health workers and hospitals in making and keeping RM or RME confidential; Second, the position and strength of RM or RME as evidence according to the law of evidence. The results show that health workers or hospitals are obliged to make Medical Records or Electronic Medical Records correctly and responsibly. Regulation of the Minister of Health Number 749a/MENKES/Per/XII/1989 concerning Medical Records is the basis for the obligation to procure Medical Records, therefore it must be adhered to for every health service.Keywords: Medical Records, Electronic Medical Records, Evidence

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电子医疗记录作为治疗交易的证据

医疗检查的结果是医患关系的证明，这种关系记录在一份记录中，其中载有根据已进行的检查结果对患者健康状况的解释。虽然记录过程是一项义务，但在一些情况下，医务人员没有正确填写病历，有些甚至没有填写病历。因此，本研究旨在找出电子病历作为治疗交易证据的紧迫性。本文研究的问题是:第一，卫生工作者和医院制定和保密RM或RME的法律后果;第二，根据证据法确定RM或RME作为证据的地位和力度。结果表明，卫生工作者或医院有义务正确、负责地制作病历或电子病历。卫生部长关于医疗记录的第749a/MENKES/Per/XII/1989号条例是采购医疗记录义务的基础，因此每项保健服务都必须遵守该条例。关键词:病历，电子病历，证据

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Jurnal Dinamika Hukum

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