Using Information Systems and Medical Records Services in Emergency Unit at RSBS, the documentation of medical records and patient handling data can be accessed online in order to facilitate the search of medical records when needed. Medical record documents in RSBS still in a paper form (not paperless) and causing physicians have difficulty in determining a patient's medical treatment following actions. Item Type:Įlectronic Medical Record, Regulation, Medical Malpractice.Medical records are one of the quality assessment of a medical service which provides information such as the details of handling cost, types of diseases and health conditions of patients that are useful for the physician to determine further actions to medical treatment in patients. For this reason, a normative legal research with a comparative approach was conducted to compare the legislation in other countries as a recommendation for the establishment of electronic medical record regulation in Indonesia in accordance with the rules for establishing legislation, so that they can be used as valid evidences in medical malpractice courts. In practice, electronic medical record can be categorized as valid evidence in a medical malpractice case court is only based on the judge's conviction. Various lawsuits against health services or known as malpractice involve evidence in the form of medical records which are opened by court order. Legislation in the form of a regulation of the minister of health only regulates medical records in general and there is no standardization and legislation regarding electronic medical record.
Currently, there is no specific legal regulation that regulates the implementation of electronic medical record in Indonesia. In the case of medical malpractice in Indonesia, medical records play an important role in the evidence in court. Various health facilities such as hospitals in big cities in Indonesia already use electronic medical records. Medical records are a form of administrative service provided by health facilities to patients that must be carried out by health workers who provide services.
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