440 - Kepemilikan dan Isi Rekam Medis #rekammedis

Summary

This video by Dr. Sufi discusses the ownership and contents of medical records in healthcare facilities. It covers the responsibilities of healthcare providers to protect medical records from loss, damage, or unauthorized use. The video explains when and how medical records can be shared with patients, their families, or others, and outlines the necessary components of medical records. Additionally, it touches on electronic medical records, detailing their administrative and clinical documentation, as well as the role of the Ministry of Health in utilizing these records for data processing and policy development. The video concludes with an invitation for feedback and discussion.

Takeaways

• 😀 The medical record is owned by healthcare facilities, which are responsible for its security, integrity, and proper use.
• 😀 Medical records can be shared with patients and their closest family members, especially in the case of minors or emergencies.
• 😀 Sharing medical records with others requires patient consent, except for certain circumstances like emergencies or legal requirements.
• 😀 A medical record must include the patient's identity, results of physical and diagnostic examinations, diagnosis, treatment plan, and the healthcare provider's name and signature.
• 😀 Medical records must be maintained by the responsible healthcare provider and should be provided to patients when discharged or referred.
• 😀 For inpatient and emergency cases, medical records must be provided at discharge, and for referrals, they should be shared with the receiving healthcare facility.
• 😀 Medical records for outpatient cases can be shared if necessary, depending on the situation.
• 😀 Electronic medical records consist of administrative and clinical documentation, with the latter detailing all healthcare services provided to the patient.
• 😀 Healthcare facilities are allowed to develop and customize the content of electronic medical records as per their healthcare needs.
• 😀 The Ministry of Health has access to the full content of electronic medical records, and it is responsible for processing and storing this data for public health purposes, including policy-making and research.
• 😀 Electronic health data can also come from other sources such as health banks or institutions, and its processing supports advancements in healthcare knowledge and evidence-based practices.

Q & A

What is the responsibility of a healthcare facility regarding medical records?

A healthcare facility is responsible for the care, preservation, and proper management of medical records. This includes preventing loss, damage, falsification, or unauthorized use of the medical documents by individuals or bodies who are not authorized to access them.

Who can receive medical records besides the patient?

Medical records can also be shared with close family members or other parties, but only under certain conditions, such as when the patient is a minor (under 18 years old) or in emergency situations.

Under what circumstances can medical records be shared with other parties?

Medical records can be shared with other parties only after receiving explicit consent from the patient.

What must be included in a medical record?

A medical record must include at least four components: 1) patient identity, 2) results from physical and supporting examinations, 3) diagnosis, treatment, and follow-up plan, and 4) the name and signature of the healthcare provider.

Who is responsible for creating medical records?

The healthcare provider responsible for the medical services is required to create and maintain the medical record.

When should a medical record be provided to a patient?

Medical records should be provided to inpatients and emergency patients upon discharge. They should also be shared with referral healthcare facilities when transferring patients.

Can medical records be shared with outpatient patients?

Yes, medical records can be provided to outpatient patients if necessary.

How are medical records shared when a patient is discharged?

When a patient is discharged, the medical record can be provided in the form of a letter, either in physical form, sent electronically via a computer network or mobile device, or in printed form.

What are the components of an electronic medical record?

An electronic medical record includes two main types of documentation: 1) administrative documentation, such as registration information, and 2) clinical documentation, which contains all details of the healthcare services provided to the patient.

How should the Ministry of Health handle electronic medical records?

The Ministry of Health is authorized to access and utilize electronic medical records for health data processing. This includes using the data for scientific research, technological development, and policy-making in the health sector, while respecting ethical standards and relevant regulations.