Medical Records: Understanding According to experts, Purpose, Types, Functions and Benefits

Medical Records: Understanding According to Experts, Purpose, Types, Functions and Benefits - What is a Medical Record?, A term that is of course used in the world of medicine. To better understand what Medical Records means, of course, it would be better for us to refer to the article below.

Medical Records: Understanding According to Experts, Purpose, Types, Functions and Benefits

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Medical records are records or records of who, what, why, when and how services are provided to patient during the treatment period, or in other words, the definition of a medical record is a record of the results of treatment of patient. The following are some definitions according to experts and laws:

Article 46 paragraph (1) of the Medical Practice Law

Medical record is a file that contains notes and documents about patient identity, examination, treatment, actions and other services that have been given to patients.

Huffman (1999)

According to Huffman, Medical Records are facts related to the patient's condition, medical history and past as well as current medications written by healthcare professionals providing services to patients the.

Law No. 29 of 2004

According to Law No. 29 of 2004 article 46 paragraph (1) concerning medical practice, medical records are files containing notes and documents regarding patient identity, medical examinations, actions and other services that have been provided to patient.

IDI (2005)

According to IDI (2005), medical records are records in written form or descriptions of service activities provided by medical or health service providers to a patient.

Hanafiah and Amir (2007)

According to Hanafiah and Amir, Medical Records are a collection of information about identity, results of anamnesis, examinations, and records of all activities of health care workers on patients from time to time.

PERMENKES Number 269/MENKES/PER/III/2008

According to PERMENKES Number 269/MENKES/PER/III/2008, medical records are files that contain records of documents about the identity of the patient, examination, treatment, action and other services that have been given to patient.

Purpose of Medical Records

The purpose of medical records according to Hatta (1985) consists of several aspects including administrative, legal, financial, research, educational and documentation aspects, which are explained as follows:

• Administrative aspects. A medical record file has administrative value because its contents involve actions based on authority and responsibility as medical and paramedical personnel in achieving service goals health.
• Medical Aspect. A medical record file has medical value, because the record is used as a basis for planning treatment / care that must be given to a patient.
• Legal Aspect. A medical record file has legal value because its contents relate to the problem of guaranteeing legal certainty on the basis of justice, in the context of efforts to enforce the law and provide evidence to enforce justice.
• Financial aspect. A medical record file has monetary value because its contents involve data and information that can be used in calculating the cost of treatment/action and care.
• Research aspect. A medical record file has research value, because its contents involve data/information that can be used in research and scientific development in the health sector.
• Educational aspect. A medical record file has educational value, because its contents involve data/information about developments/chronology and activities of medical services provided to patients. This information can be used as teaching materials/references in the field of health professions.
• Documentation aspect. A medical history file has a documentation value, because its contents involve a source of memories must be documented and used as material for accountability and service facility reports health.

Benefits of Medical Records

According to the Indonesian Medical Council (2006), the benefits of medical records include:

• Patient Treatment
  Medical records are useful as a basis and guide for planning and analyzing disease and planning treatment, care and medical actions that must be given to patients.
• Service Quality Improvement
  Making clear and complete medical records for carrying out medical practice will improve quality of service to protect medical personnel and to achieve public health optimal.
• Education and Research
  Medical record which is information on the chronological development of the disease, medical services, treatment and medical action, useful for information material for the development of teaching and research in the field of medical and medical professions tooth.
• Financing
  Medical record files can be used as a guide and material for determining the financing of health services at health facilities. These records can be used as proof of financing to patients.
• Health Statistics
  Medical records can be used as material for health statistics, especially to study public health developments and to determine the number of sufferers of certain diseases.
• Proof of Legal, Discipline and Ethical Issues
  Medical records are the main written evidence, so they are useful in solving legal, disciplinary and ethical issues.

Use of Medical Records

The uses of medical records include:

• As a communication tool between doctors and other health workers who take part in providing services, treatment, care to patients.
• As a basis for planning treatment / care given to patients.
• As written evidence of all service actions, disease progression and treatment while the patient is visiting/treated.
• As material for analysis, research and evaluation of the quality of services provided to patients.
• Protecting the legal interests of patients, hospitals as well as doctors and other health workers.
• Providing special data that is very useful for research and education purposes.
• As a basis for calculating the cost of paying for patient medical services.
• Become a source of memory that must be documented, as well as material for accountability and reports.

Types of Medical Records

Based on the storage time, there are 2 (two) types of medical records, namely:

Active Medical Record File

namely medical record files that are still actively used in health care facilities such as hospitals and are still stored in medical record file storage areas.

Inactive Medical Record Files

namely medical record files that if they have been kept for at least five years in the medical record work unit are counted since the last date the patient was served at a health care facility or five years after death world.

Contents and Recording of Medical Record Data

Fill in the Medical Record

According to the Indonesian Medical Council (2006), the medical record contains two contents, namely:

• Notes, namely a description of the patient's identity, patient examination, diagnosis, treatment, action and other services either performed by doctors and dentists or other health workers in accordance with competence.
• Documents, namely the completeness of the records, such as X-rays, laboratory results and other information in accordance with scientific competence.

Medical Record Data

According to Guwandi (1992), there are 4 (four) types of data in medical records, including:

• Personal data, this includes the patient's identity starting from name, no. ID card, address, place of birth, date of birth, type gender, occupation, immediate family, registration number, treating doctor, origin of referral, entry date, and date go out.
• Financial data, namely data from the person in charge, address, company, insurance company that underwrites, type of insurance and policy number.
• Social data, namely data on citizenship, nationality, family relations, livelihoods, community activities and data on the patient's social position.
• Medical data, namely patient medical data from anamnesis, physical examination, general condition/pulse, blood pressure, diagnosis at admission, notes treatment, patient progress/deterioration, doctor's instructions, supporting examinations, laboratories, X-rays, EKG, nurse's reports, consultations, operations, and other action records while the patient is out of the hospital and the name of the doctor who treats the patient and the date.

Storage and Archiving of Medical Records

Medical records are stored according to the patient registration number or medical record number which is sorted based on the final number (terminal digit), middle number (middle digit) or direct number (straight numerical). According to the Indonesian Ministry of Health (2006), based on the location where medical record files are stored, medical record storage is divided into two types, namely:

Centralization

Central medical record document storage system, namely a storage system by unifying medical record files for outpatient, inpatient, and emergency care patients into a single folder storage.

Decentralization

The medical record document storage system is decentralized, namely a storage system by separating medical record files for outpatients, emergency care, and inpatients in separate folders and/or places alone. Usually the medical record files for outpatient and emergency care are stored on a medical record file storage rack in the medical record unit or outpatient registration area. while inpatient medical record files are stored in another storage room, such as in a ward or record unit that is separate from the inpatient medical record storage area the way.

Procedures for Organizing Medical Records

The following are several procedures for organizing medical records, consisting of:

Procedures

Article 46 paragraph (1) of the Medical Practice Law stipulates that doctors and dentists are required to make medical records in practicing medicine. After providing medical practice services to patients, doctors and dentists immediately complete the medical record by filling out or writing all medical practice services that have been he did.

Each note in the medical record must be affixed with the name, time and signature of the officer providing the service or action. If the recording of medical records uses electronic information technology, the obligation to affix the signature can be replaced by using a personal identification number (PIN).

In the event of an error when recording in the medical record, records and files may not be removed or deleted in any way. Changes to records of errors in the medical record can only be done by crossing out and then affixing the initials of the officer concerned. Further explanation of this procedure can be read in the Regulation of the Minister of Health concerning Medical Records and guidelines for its implementation.

Ownership of Medical Records

According to the Medical Practice Law, medical record files belong to doctors, dentists or health care facilities, while the contents of medical records and document attachments belong to the patient.

Medical Record Storage

Medical records must be stored and kept confidential by doctors, dentists and leaders of health facilities. According to the Regulation of the Minister of Health, the maximum storage time is 5 years and medical record resumes are at least 25 years.

Organizing Medical Records

The organization of medical records is in accordance with the Regulation of the Minister of Health Number 749a/Menkes/Per/XII/1989 concerning Medical Records (currently being revised) and implementation guidelines.

Guidance, Control and Supervision

For the Guidance, Control and Supervision of the Medical Record stage it is carried out by the central government, the Indonesian Medical Council, local governments, professional organizations.

Medical Record Flow

The flow of outpatient medical records from registration to storage of medical records in outline (According to the Ministry of Health) is as follows (Ministry of Health, 1997: 15):

Patients buy tickets at the registration counter.
Patients with tickets register at the outpatient reception area.
The receptionist, outpatient patient records in the register book the patient's name, medical record number, identity, and patient's social data and records complaints on the polyclinic card.
The officer at the reception area makes a medical card to give to the patient, which must be brought with him or her for repeated treatment.
Repeat patients who already have a treatment card besides having to show the ticket must also show the treatment card to the officer who will take the repeat patient's medical record file.
The polyclinic card is sent to the intended polyclinic according to the patient's complaints, while the patient comes to the polyclinic by himself.
The polyclinic officer records in the Outpatient Patient Register book the name, medical record number, type of visit, action or service provided and so on.
Officers at the Polyclinic (nurse) make reports or daily recapitulation of outpatient patients.
The medical record officer checks the completeness of the Medical Record filling and for those that are not complete, efforts are made to complete them immediately.
The medical record officer makes a recap at the end of each month, to make reports and hospital statistics.
The patient's Medical Record file is stored according to the Medical Record number (Januarsyah, 1999: 79)

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