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"Catatan medis menjelaskan perjanjian kerahasiaan medis di Indonesia dan Amerika Serikat; Perjanjian Implementasi Telemedicine di Indonesia dan Amerika Serikat; dan menganalisis undang-undang tentang kerahasiaan rekam medis elektronik dalam penerapan telemedicine di Indonesia dan Amerika Serikat menggunakan metode penelitian yuridis normatif. Dari hasil penelitian yang diakui (1) Kerahasiaan rekam medis di Indonesia dilindungi oleh berbagai peraturan seperti Hukum dan Peraturan Menteri sementara di Amerika Serikat, kerahasiaan pasien dalam rekam medis yang didukung oleh peraturan nasional, HIPAA, serta peraturan dan keputusan pengadilan negara; (2) Implementasi telemedicine di Indonesia belum diatur oleh pemerintah Amerika Serikat yang peraturannya telah diatur baik di tingkat nasional maupun negara bagian dan keputusan pengadilan dalam memastikan tata kelola telemedicine yang baik. Rekam medis pada sistem telemedicine, baik di Indonesia dan Amerika Serikat rekam medis dalam pelaksanaan telemedicine dalam bentuk ESDM dan bersama-sama didukung oleh hukum Amerika Serikat selain sanksi untuk kerahasiaan rekam medis elektronik juga memberikan insentif keuangan untuk kerahasiaan rekam medis menurut peraturan masing-masing negara berbeda dalam hal pengecualian terhadap kerahasiaan rekam medis seperti yang ditampilkan di negara bagian Alaska danHawaii. Hasil penelitian tersebut, peneliti mengusulkan Menteri Kesehatan segera membuat pengaturan untuk pedoman terkait telemedis dalam implementasi telemedis tingkat nasional dengan menyediakan pengaturan yang dapat digunakan sebagai referensi dalam hal catatan medis elektronik seperti standar enkripsi yang digunakan.

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Medical records explain medical confidentiality agreements in Indonesia and the United States. Telemedicine Implementation Agreement in Indonesia and America Union and analyzing the law on the confidentiality of electronic medical records in the application of telemedicine in Indonesia and the United States using normative juridical research methods. From the results of research that are recognized (1) The confidentiality of medical records in Indonesia is protected by various regulations such as Law and Ministerial Provisions in the United States, the confidentiality of patients in medical records supported by national regulations, HIPAA, and regulations and decisions of state courts; (2) The implementation of telemedicine in Indonesia has not been regulated by the United States government whose regulations have been set at both the national and state levels and court decisions in ensuring good telemedicine governance; Medical records on the telemedicine system, both in Indonesia and the United States. Medical records on the implementation of telemedicine in the form of EMR and together supported by United States law in addition to sanctions for the confidentiality of electronic medical records also provides financial incentives for the confidentiality of medical records according to the regulations of each different country in terms of exceptions to the confidentiality of medical records as displayed in the state of Alaska and Hawaii. The results of the study, researchers proposed the Minister of Health immediately make arrangements for guidelines relating to telemedicine in the implementation of national telemedicine by providing arrangements that can be used as a reference in terms of electronic medical records such as the encryption standards used."

"Perlindungan rahasia medis dan rekam medis merupakan suatu kewajiban dalam penyelenggaraan pelayanan kesehatan. Saat ini, penggunaan aplikasi layanan kesehatan di Indonesia semakin menjadi suatu tren kesehatan baru di masyarakat oleh karena pasien dapat mendapat layanan kesehatan, khususnya berkonsultasi dengan dokter, sesuai dengan permasalahan kesehatan yang sedang diderita. Aplikasi layanan kesehatan bukan merupakan penyelenggara jasa kesehatan sehingga sampai saat ini  belum ada peraturan khusus yang mengatur tanggung jawab perlindungan rahasia medis dan rekam medis oleh aplikasi layanan kesehatan. Hal ini menimbulkan potensi risiko hukum yang dapat mengakibatkan terlanggarnya kerahasiaan data dan riwayat kesehatan pasien pengguna aplikasi layanan kesehatan. Melalui metode penelitian yuridis normatif, penulis akan mengumpulkan data melalui studi pustaka yang hasilnya akan dipaparkan secara deskriptif. Dalam penelitian ini, berdasarkan Terms and Conditions dari masing-masing aplikasi layanan kesehatan, penulis menyimpulkan sampai saat ini perlindungan rahasia medis dan rekam medis pada aplikasi layanan kesehatan Halodoc, Alodokter, KlikDokter, dan Good Doctor belum diterpakan sebagaimana ketentuan dalam peraturan perundang-undangan. Selain itu, pengaturan perlindungan rahasia medis dan rekam medis yang berlaku pada saat ini masih hanya sebatas mewajibkan kepada kesehatan saja. Tanggung jawab dari aplikasi layanan kesehatan dalam perlindungan rahasia medis dan rekam medis pasiennya seharusnya diatur dalam pengaturan khusus.

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Legal protection of medical confidentiality and medical records is an obligation in the administration of health services. Nowadays, the utilizarion of health service apps in Indonesia is increasingly becoming a new health trend in society since patients will able to receive health services, particularly consulting with the doctors, based health problems being suffered. Health service apps are not health service providers, then until now there are no specific regulation about the responsibility of protecting medical secrets and medical records by health service applications. This raises potential legal risks that can result in breaches of confidentiality of data and medical history of patients that using the health service apps. Through normative juridical research methods, the writer will collect data through a literature study whose results will be presented descriptively. In this study, based on the Terms and Conditions of each health service apps, the author concludes that until now the protection of medical confidentiality and medical records on Halodoc, Alodokter, KlikDokter, and Good Doctor health service apps has not been applied as stipulated in the current regulation. In addition, currently the regulation of the protection of medical confidentiality and medical records is still limited to requiring health. The responsibility of the application of health services in the protection of medical secrets and medical records of patients should be regulated in a specific regulation."

"ABSTRACTPerlindungan rahasia medis merupakan salah satu aspek terpenting dalam pelayanan medis yang diberikan oleh setiap tenaga medis kepada pasien yang membutuhkan. Rahasia medis menyangkut hak privasi pasien sebagai manusia yang tidak dapat dilanggar dan wajib untuk dipenuhi secara hukum. Dalam kondisi darurat sekalipun seperti dalam keadaan bencana, pelayanan medis harus tetap mengutamakan serta menjunjung tinggi standar profesi serta etika medis berupa perlindungan rahasia medis serta pemenuhan hak privasi pasien. Sebagai bentuk dari tanggung jawab hukum relawan pelayanan medis, tidak terkecuali terhadap relawan medis asing. Metode yang digunakan dalam penelitian ini ialah metode yuridis normatif dengan menggunakan sumber teks undang-undang dan bahan-bahan bacaan lainnya sebagai sumber yang nanti akan dipaparkan menggunakan tipe deskriptif untuk memperoleh gambaran tentang keadaan hukum yang berlaku di Indonesia. Penelitian ini mencoba menganalisis peraturan perundang-undangan di Indonesia. Penulis menemukan bahwa kewajiban perlindungan terhadap rahasia medis pasien korban bencana alam di Indonesia juga dimiliki oleh tenaga kesehatan warga negara asing TKWNA atau relawan medis yang melakukan upaya penaganan serta penanggulangan bencana di Indonesia, walaupun pengaturan tersebut tidak dijelaskan secara eksplisit di dalam peraturan perundang-undangan terkait penanggulangan bencana, namun secara harfiah setiap tenaga medis memiliki kewajiban dalam menaati standar profesi serta etika medis yang diatur oleh organisasi profesi di negaranya masing-masing, etika medis tersebut bersifat universal karena menyangkut kehormatan sebuah profesi medis. Untuk dapat melindungi rahasia medis sebagai hak privasi pasien korban bencana alam Badan Nasional Penanggulangan Bencana berkoordinasi dengan Kementrian Kesehatan dianjurkan untuk membuat peraturan khusus terkait perlindungan hak-hak medis pasien korban bencana alam termasuk perlindungan rahasia medis.

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ABSTRACTProtection of medical confidentiality is one of the most important aspects of medical services provided by every medical doctor to patients in need. Medical confidentiality revolves around the patients privacy rights as a human being that cannot be violated and is obliged to be fulfilled legally. Even in an emergency conditions such as disaster, medical services must continue to prioritize and uphold professional standards and medical ethics in the form of medical confidential protection and fulfillment of patients privacy rights. As a form of the legal responsibility of medical service volunteers, it is no exception to foreign medical volunteers. The method used in this research is a normative juridical method by using the source of the text of the law and other reading materials as a source which will later be presented using descriptive types to obtain an overview of the conditions of the applicable law in Indonesia. This research tries to analyze the laws and regulations in Indonesia. The author finds that the obligation to protect medical secrets of victims of natural disasters in Indonesia is also owned by health workers of foreign TKWNA or medical volunteers who carry out efforts to manage and manage disasters in Indonesia, even though these arrangements are not explicitly explained in the relevant laws and regulations disaster management, but on a daily basis every medical person has an obligation to comply with professional standards and medical ethics regulated by professional organizations in their respective countries, medical ethics are universal because they involve the honor of a medical profession. To be able to protect medical secrets as the privacy rights of natural disaster victim patients,  the National Disaster Management Agency coordinates with the Ministry of Health, it is recommended to make special regulations related to the protection of medical rights of victims of natural disasters including the protection of medical confidentiality."

"ABSTRAKSkripsi ini membahas mengenai kegiatan penyimpanan arsip aktif maupun inaktif di sebuah instalasi rekam medis rumah sakit. Penelitian ini merupakan penelitian kualitatif menggunakan metode studi kasus. Hasil penelitian ini adalah penyimpanan terhadap rekam medis merupakan salah satu kegiatan yang berfungsi sebagai tindak lanjut rekam medis untuk ke depannya menjadi acuan tenaga kesehatan maupun pihak lain yang berwenang dalam penggunaannya. Rumah sakit menyimpan rekam medis dalam institusinya sendiri untuk memudahkan temu kembali dan pengamanan lebih terpercaya. Saran penelitian ini yaitu pembenahan rekam medis secara menyeluruh agar tertata rapi.

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ABSTRACTThis thesis discussed about the storage of medical record in a hospital.The research is the qualitative study in a case study.The result of this research is a depository to medical records is one of the that serves as a follow-up record medical to in the future is used to health workers and other parties that authorized the use of. The hospital keep medical records in institutional own to ease common ground back and security more credible. Advice for this research is to improve the slums of medical record in thorough that orderly."

"[ABSTRAKTesis ini membahas analisis kelengkapan rekam medis rawat inap RSKO Jakartatahun 2014. Penelitian ini adalah penelitian mixed method yaitu penelitian secarakuantitatif dan kualitatif. Penelitian kualitatif digunakan untunk mengetahui nilaikelengkapan rekam medis, dan penelitian kualitatif untuk menggali informasiterhadap input, proses, dan output. Hasil penelitian menunjukkan bahwa nilaikelengkapan rekam medis hanya 62,6% belum mencapai standard 100%. Padapenelitian kualitatif didapatkan hasil bahwa faktor input; sumber daya manusia,material, infrastruktur, dan prosedur, faktor proses; pengisian rekam medis danmonitoring evaluasi, dapat mempengaruhi kelengkapan rekam medis (faktoroutput). Rumah sakit harus membenahi faktor input dan proses agarneningkatkatkan nilai kelengkapan rekam medis sesuai standar sehingga dapatmeningkatkan kualitas pelayanan kesehatan di RSKO Jakarta.

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ABSTRACTThis thesis describes completeness of inpatient medical records at RSKO Jakartahospital on 2014. This research used mixed methods, consists of quantitative andqualitative research. Quantitative research is used to determine the completenessvalue of medical records, and then qualitative research is used to get informationfrom the input, process, and output. The result showed that the completenessvalue of inpatient medical records only 62,6% and it didn?t reach the target of100 % standard. On qualitative research showed that input factors consisted ofhuman resources, materials, infrastructures, and procedures, Process factorsconsisted of medical records recording, monitoring and evaluation, are influencesby completeness of medical records (output factors). Hospital must improve inputfactors and process factors in order to increase the good completeness value, toimprove the quality of medical services at RSKO Jakarta.;This thesis describes completeness of inpatient medical records at RSKO Jakartahospital on 2014. This research used mixed methods, consists of quantitative andqualitative research. Quantitative research is used to determine the completenessvalue of medical records, and then qualitative research is used to get informationfrom the input, process, and output. The result showed that the completenessvalue of inpatient medical records only 62,6% and it didn?t reach the target of100 % standard. On qualitative research showed that input factors consisted ofhuman resources, materials, infrastructures, and procedures, Process factorsconsisted of medical records recording, monitoring and evaluation, are influencesby completeness of medical records (output factors). Hospital must improve inputfactors and process factors in order to increase the good completeness value, toimprove the quality of medical services at RSKO Jakarta., This thesis describes completeness of inpatient medical records at RSKO Jakartahospital on 2014. This research used mixed methods, consists of quantitative andqualitative research. Quantitative research is used to determine the completenessvalue of medical records, and then qualitative research is used to get informationfrom the input, process, and output. The result showed that the completenessvalue of inpatient medical records only 62,6% and it didn’t reach the target of100 % standard. On qualitative research showed that input factors consisted ofhuman resources, materials, infrastructures, and procedures, Process factorsconsisted of medical records recording, monitoring and evaluation, are influencesby completeness of medical records (output factors). Hospital must improve inputfactors and process factors in order to increase the good completeness value, toimprove the quality of medical services at RSKO Jakarta.]"

"Penulisan ini dilatarbelakangi atas perkembangan teknologi informasi yang menguasai hampir keseluruhan aspek kehidupan di dalam suatu negara, khususnya di bidang kesehatan. Dalam hal ini mengenai rekam medis elektronik di Rumah Sakit Cipto Mangunkusumo. Peraturan perundang-undangan tentang Rekam Medis telah mengakui adanya rekam medis elektronik, akan tetapi pengaturan yang secara spesifik mengatur penyelenggaraan rekam medis elektronik belum ada sampai dengan saat ini. Penulisan ini dilakukan untuk menjawab tiga permasalahan pokok mengenai, pengaturan rekam medis elektronik di Indonesia, tanggung jawab hukum rumah sakit dalam penyelenggaraan rekam medis elektronik, dan penerapan rekam medis elektronik di Rumah Sakit Cipto Mangunkusumo. Peraturan perundang-undangan yang digunakan dalam penulisan ini adalah, Undang-Undang Nomor 29 Tahun 2004 tentang Praktik Kedokteran, Undang-Undang Nomor 11 Tahun 2008 serta perubahannya Undang-Undang Nomor 11 Tahun 2016  tentang Informasi dan Transaksi Elektronik, dan Peraturan Menteri Kesehatan Nomor 269 Tahun 2008 tentang Rekam Medis. Hasil penulisan ini menunjukkan bahwa penyelenggaraan rekam medis elektronik secara hukum tidak memiliki dasar hukum yang memadai, sehingga menghambat pemanfaatan dari rekam medis elektronik itu sendiri. Akan tetapi, rumah sakit sebagai pihak yang menyelenggarakan rekam medis elektronik tetap memiliki kewajiban untuk bertanggungjawab apabila terjadi kerugian dikemudian hari

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This study was motivated by the development of technology that appear almost in every aspects of life especially in the field of health. In this case the study held in electronic medical records at Cipto Mangunkusumo. The law on Conventional Medical records, have acknowledged about electronic medical records, but the regulations that are specifically governing the implementation of electronic medical records  are not regulated yet. This writing is to used to answer three main questions. The first one is the regulation of electronic medical records in Indonesia, the second one is hospital responsibility in implementing electronic medical records, and last one is the implementation of electronic medical records at Cipto Mangunkusumo Hospital. The regulations that used in this study are, Indonesian Law Number 29 Year 2004 about Medical Practice, Indonesian Law Number 11 Year  2016 about Information and Electronic Transactions, dan Minister of Health Regulations Number 269 Year 2008 about Medical Records. The result of this study has shown that the implementation of electronic medical records does not have a clear legal basis, that could be an obstacles for the development of electronic medical records itself. However, the hospital will still hold a responsibilty if there is a disadvantage about electronic medical record  in the future."

"Analisis Kelengkapan Pengisian Informed consent Pada Rekam Medis Pasien Tindakan Bedah di RS X Tahun 2016 Penelitian ini membahas kelengkapan pengisian informed consent tindakan bedah di RS X tahun 2016. Tujuan penelitian ini adalah agar dapat mengetahui gambaran kelengkapan pengisian informed consent tindakan bedah. Jenis penelitian ini adalah kuantitatif dengan pengisian kuesioner dan kualitatif dengan wawancara mendalam dan telaah dokumen formulir informed consent menggunakan daftar tilik serta menggunakan data sekunder. Dari hasil penelitian ini didapatkan sebanyak 56,9 dari total formulir yang diamati telah diisi secara lengkap.Hasil penelitian ini menunjukkan bahwa belum adanya Standar Prosedur Operasional dan Kriteria tentang kelengkapan pengisian formulir informed consent tindakan bedah. Hal tersebut dapat menjadi salah satu faktor yang menyebabkan tidak lengkapnya pengisian formulir informed consent tindakan bedah di RS X.

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Analysis of the Completeness of Filling Informed consent Forms in Surgery Patients Medical Record at Hospital X 2016 This study explores the completeness of filling surgery informed consent forms at Hospital X in 2016. The aim of this study is to illustrate the degree of completeness of filled in consent forms pertaining to surgical actions. The design of this study uses a quantitative method through questionnaires, a qualitative method through in depth interviews and document review informed consent forms through checklists, and also the use of secondary data.

Results of this study shows that an average of 56.9 of consent forms were completely filled. This study also reveals that there is a lack of Standard Operating Procedure and criteria about completed informed consent forms for surgery, which may be one of the factors contributing to incomplete surgery informed consent forms at Hospital X."

"ABSTRAKPenelitian ini membahas mengenai proses penciptaan rekam medis di Klinik Terpadu Fakultas Psikologi Universitas Indonesia (KTFP UI). Penelitian ini bertujuan untuk mendeskripsikan penciptaan rekam medis di KTFP UI dengan menggunakan model penciptaan rekod yang dijelaskan oleh Shepherd dan Yeo (2003) yakni identifikasi kebutuhan, proses penciptaan serta pengelolaan rekam medis. Metode yang digunakan adalah pendekatan kualitatif dengan studi kasus. Teknik pengumpulan datanya melalui observasi, wawancara dan analisis dokumen. Hasil dari penelitian ini menunjukkan bahwa rekam medis di KTFP UI tercipta secara alami dan cukup sederhana. Belum ada aturan tertulis tentang penciptaan rekam medis. Penciptaan rekam medis ditujukan sebagai rujukan untuk tindakan lanjutan, sarana memonitor, dan sebagai alat komunikasi antar profesional baik internal maupun lintas instansi. Dalam prosesnya autentisitas dijaga dengan mencantumkan nama psikolog, klien serta waktu pelayanan. Pada tahap penyimpanan rekam medis belum sesuai kaidah profesional kearsipan sehingga berakibat pada kurang lancarnya penemuan kembali. Yang penting adalah menambah pengetahuan dan pemahaman para arsiparis rekam medis di KTFP UI dengan memberikan pelatihan manajemen kearsipan sehingga penciptaan rekam medis di KTFP UI menjadi lebih baik.

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ABSTRACTThis study discusses about the process of creating medical records at the Integrated Clinic Faculty of Psychology, University of Indonesia (KTFP UI). The purpose of this study is to describe the creation of medical records at KTFP UI by using a model of creating records described by Shepherd and Yeo (2003), namely identification of needs, the process of creating, and capturing medical records. The method used is a qualitative approach with case studies. The data collection technique is through observation, interviews and document analysis. The results of this study indicate that medical records at KTFP UI were created naturally and quite simple. There are no written rules regarding the creation of medical records. The creation of medical records is intended as a reference for follow-up actions, means of monitoring, and as a communication tool between professionals both internally and across agencies. In the process, authenticity is maintained by including the name of the psychologist, client and service time. At the stage of storing medical records it is not yet in accordance with the professional rules of archiving so that it results in retrieval difficulties. The important thing is to increase the knowledge and understanding the archivists of medical records at KTFP UI by providing filing management training so that the creation of medical records at KTFP UI becomes better."