scholarly journals SOSIALISASI PELAKSANAAN SISTEM PENYIMPANAN BERKAS REKAM MEDIS DI KLINIK AS SALAM KOTA PADANG

2019 ◽  
Vol 3 (2(Jul-Des)) ◽  
pp. 130
Author(s):  
Sayati Mandia
Keyword(s):  
Health Service ◽  
Community Engagement ◽  
Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Storage System ◽  
Physical Damage ◽  
Filling System ◽  
Medical Person ◽  
Speed Up

Klinik merupakan pelayanan kesehatan yang menyelenggarakan dan menyediakan pelayanan medis dasar  atau spesialistik, dan diselenggarakan oleh satu atau lebih tenaga kesehatan  dan dipimpin oleh seorang tenaga medis. Setiap klinik wajib menyelenggarakan rekam medis. Salah satu penyelenggaran rekam medis adalah sistem penyimpanan berkas rekam medis. Sistem penyimpanan ini sangat penting untuk dilakukan karena dapat mempermudah berkas rekam medis yang akan disimpan dalam rak penyimpanan, mempercepat ditemukan kembali atau pengambilan berkas rekam medis yang disimpan dalam rak penyimpanan, mudah pengembaliannya, dan melindungi berkas rekam medis dari bahaya pencurian, bahaya kerusakan fisik, kimiawi, dan biologi. Pengabdian kepada masyarakat ini dilakukan dengan cara memberi sosialisasi kepada petugas rekam medis mengenai penyimpanan berkas rekam medis. Pengabdian ini membahas mengenai sistem penyimpanan yang dilaksanakan di klinik As salam kota padang. Hasil pengabdian ini berupa penambahan wawasan mengenai sistem penyimpanan rekam medis pasien. Kata kunci: Sistem Penyimpanan, Rekam medis, Klinik ABSTRACT Clinic is a health service that organizes and provides basic or specialist medical services, and is organized by one or more health workers and is led by a medical person. Each clinic is required to hold a medical record. One of the organization of medical records is a medical record filling system. Filling is very important because it can facilitate the medical record file to be stored in a storage rack, speed up rediscovering or retrieving medical record files stored in a storage rack, easy return, and protect medical record files from the danger of theft, physical damage, chemistry and biology. The community engagement is done by giving socialization to medical records officer regarding the filling of medical record files. This engagement discusses that filling system implemented in Clinis As salam. The results is increasing knowledge about medical record filling system.Keywords: Storage system, Medical record, Clinic

scholarly journals PENINGKATAN PENGETAHUN MASYARAKAT TERKAIT PENTINGNYA REKAM MEDIS BAGI PASIEN DI FASILITAS PELAYANAN KESEHATAN

2021 ◽  
Vol 5 (1) ◽  
pp. 163
Author(s):  
Romaden Marbun ◽  
Rea Ariyanti ◽  
Vincensia Dea
Keyword(s):  
Health Care ◽  
Health Service ◽  
Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Personal Information ◽  
Care Facility ◽  
Health Care Facilities ◽  
Public Knowledge ◽  
Maximum Point

ABSTRAKRekam medis merupakan bagian dari arsip yang menggambarkan segala aktivitas sebuah fasilitas pelayanan kesehatan dalam kurun waktu tertentu. Rekam Medis ialah berkas yang berisikan catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan, dan pelayanan lain yang telah diberikan kepada pasien. Rekam medis ini memiliki fungsi penting bagi pasien dan juga dokter. Oleh karena itu pengisian rekam medis ini harus lengkap dan tidak boleh ditunda pengisiannya baik bagi pasien ataupun tenaga kesehatan. Namun, banyak masyarakat yang belum mengetahui fungsi penting dari melengkapi rekam medis dan keterbukaan informasi pribadinya yang harus diberikan kepada fasilitas pelayanan kesehatan bahkan tenaga kesehatan yang merawatnya dalam menunjang mutu informasi pada rekam medis tersebut. Tujuan kegiatan ini adalah meningkatkan pengetahuan masyarakat khususnya RT 09 Kelurahan Bandulan Kota Malang tentang pentingnya rekam medis bagi masyarakat yang berobat di fasilitas pelayanan kesehatan. Metode penyuluhan dilakukan secara tidak langsung atau dalam jaringan (daring) dengan berkoordinasi via online grup whatsapp selama 3 kali pertemuan serta dikirimkan materi presentasi serta video pembelajaran. Masyarakat yang terlibat sebanyak 34 orang. Tahap evaluasi dilakukan melalui google form. Hasil kegiatan diperoleh peningkatan pengetahuan masyarakat dari rata-rata 37,53 menjadi 79,06 dengan point maksimal 100. Kegiatan berjalan dengan baik dan perlu adanya monitoring lebih lanjut. Kata kunci: pengetahuan; masyarakat; rekam medis; fasilitas pelayanan kesehatan. ABSTRACTThe medical record is part of the archive that describes all the activities of a health care facility within a certain period of time. Medical Record is a file that contains records and documents about the patient's identity, examination, treatment, action, and other services that have been provided to the patient. This medical record has an important function for patients as well as doctors. Therefore, the filling of this medical record must be complete and the filling should not be delayed either for the patient or the health worker. However, many people do not know the important function of completing medical records and the disclosure of personal information that must be provided to health care facilities and even health workers who take care of them in supporting the quality of information in the medical record. The purpose of this activity is to increase public knowledge, especially RT 09 RW 05 Kelurahan Bandulan Malang City about the importance of medical records for people who seek treatment at health service facilities. The counseling method is carried out indirectly or online by coordinating via online WhatsApp groups for 3 meetings and sending presentation materials and learning videos. There were 34 people involved. The evaluation stage is carried out through a google form. The results of the activity obtained an increase in public knowledge from an average of 37.53 to 79.06 with a maximum point of 100. The activity went well and needed further monitoring. Keywords: knowledge; public; medical records; health service facilities.

scholarly journals Tinjauan Pelaksanaan Sistem Penyimpanan Rekam Medis Berdasarkan Standar Akreditasi Di UPTD Puskesmas Kotanopan Mandailing Natal

2021 ◽  
Vol 6 (1) ◽  
pp. 14-22
Author(s):  
Zulham Andi Ritonga ◽  
Hasran Ependi Lubis
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Storage System ◽  
Patient Medical Record ◽  
Biological Damage ◽  
Descriptive Research ◽  
Accreditation Standards ◽  
File Storage ◽  
Speed Up ◽  
Storage Racks

Storage of medical records is one of the assessments in puskesmas accreditation standards. The medical record file storage system is very important to do in health care institutions, because the storage system can make it easier for medical record files to be stored in storage racks, speed up the recovery or retrieval of medical record files stored on storage racks, easy to return, and protect record files. from theft, physical, chemical and biological damage. The purpose of this study was to determine how the implementation of a medical record storage system based on puskesmas accreditation standards, which was carried out in August 2020. The research method used was descriptive research with a qualitative approach. The number of research informants was 4 people. Storage of medical records had not used tracers and expedition book as a means of replacing medical record files and notes in and out of borrowed medical record files. Meanwhile, tracer and expedition books can assist officers in searching for missing / out of place medical record files. This can hamper the provision of patient medical record files that are needed. It is hoped that the UPTD Puskesmas Kotanopan will provide regular training or debriefing to medical record officers

scholarly journals Aspek Hukum Rekam Medis atau Rekam Medis Elektronik sebagai Alat Bukti Dalam Transaksi Teurapetik

2017 ◽  
Vol 3 (2) ◽  
pp. 359-383 ◽  
Author(s):  
Sudjana Sudjana
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Legal Aspects ◽  
Literature Study ◽  
Descriptive Research ◽  
Positive Law ◽  
Approach Method ◽  
Administrative Sanctions

This study aims to obtain information on: first, the obligation to create and conceal Electronic Medical Record and its juridical consequences; Secondly, due to the law of absence or error in the manufacture of Electronic Medical Records and the position of Electronic Medical Record as a tool in the theoretical transactions.The research method used is normative juridical approach method, analytical descriptive research specification, research phase is done through literature study to examine primary law material, secondary law material, and tertiary law material. Data collection techniques are conducted through document studies, conducted by reviewing documents on positive law. Furthermore, the method of data analysis is done through normative qualitative.The results of the study indicate: Legal aspects of Medical Record or Electronic Medical Record   in Teurapetik Transactions related to: first, the obligation of health workers in coaching and health services to make Medical Record or Electronic Medical Record correctly and responsible for secrecy because it is the opening of Medical Record or Electronic Medical Record without With the permission of the patient having the consequences of criminal law. The absence or misuse of the Medical Record or Electronic Medical Record means that health workers may be subject to criminal, civil and administrative sanctions. Second, the position of  Medical Record or Electronic Medical Record is evidence in the form of a letter (if given outside the court), and expert information (if delivered in court).

scholarly journals Medical Record Storage System Analysis On The Effectiveness Of Patient Services

2021 ◽  
Vol 1 (1) ◽  
pp. 28-38
Author(s):  
Yoki Muchsam ◽  
Ilham Rizkiana Muharam
Keyword(s):  
Public Health ◽  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
System Analysis ◽  
Storage System ◽  
Health Care Facilities ◽  
Public Health Center ◽  
Additional Tool ◽  
Alignment System

This study aims to determine and analyze the medical record storage system on the effectiveness of patient care at the Cikole Public Health Center. The research method used is quantitative with inferential statistical analysis techniques. Data collection techniques by means of observation, interviews and questionnaires. Cikole Lembang Public Health Center is one of the first level health care facilities. Based on observations, the storage system used is a regional storage system in which each region starts from the first digit. There are 2 officers who work in the medical records section of the Cikole Public Health Center. With the storage system used, there are several shortcomings, namely the occurrence of misfiles and duplication. To find out whether there is an analysis of the medical record storage system on the effectiveness of the service, the author gives a questionnaire to the Cikole Public Health Center officers. The results of the questionnaire also show that the highest percentage level is found in item no.7, namely the decentralized storage system is in accordance with the target of 71%. Then the second is item no. 8, namely a decentralized storage system that allows the provision of medical record files on time by 61%. From the results of interviews with medical records officers, suggestions and input were given: (1). The storage system used was changed to centralization so that the alignment system was not duplicated; (2). The use of bindex as an additional tool to make storage neater and easier.

scholarly journals Tinjauan Pelepasan Informasi Rekam Medis Kepada Pihak Ketiga Di RSU Imelda Pekerja Indonesia Medan

2021 ◽  
Vol 6 (2) ◽  
pp. 183-188
Author(s):  
Erlindai Purba ◽  
Hesty Afriani Sidabutar
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Research Method ◽  
Quantitative Methods ◽  
Health Workers ◽  
Death Certificates ◽  
Or Education ◽  
Patient Medical Record ◽  
Objective State ◽  
Regular Training

The Imelda Workers General Hospital of Indonesia does not yet have specific routines regarding the release of medical record information to third parties. however, they have used regular procedures for providing information and borrowing medical records in general, This study aims to determine the number of requests for medical record information. This type of research is descriptive, namely the research method carried out with the aim of making an objective state. The population was 4 people and the sample size was 4 people as the total sampling with the research methodology using quantitative methods. How to collect data by interview and observation. The results showed that the services of the Imelda Hospital for Indonesian Workers in Medan according to legalized death certificates amounted to 34 percent (0.56%), claims for raharja services amounted to 56 percent (0.92%), audits and insurance claims were 69 percent (1.14%) , research or education as much as 54 percent (0.89), post mortem as much as 28 percent (0.46%), BPJS as much as 5,790 percent (99.00%). Based on the results of the study, it is known that knowing the data on the number of requests for medical record information in January-June 2020 is 6,224 with a percentage (99.97%). As well as the absence of a special SPO on procedures and utilization of medical record information of deceased patients, however, they have used the permanent procedure of providing information and borrowing medical records in general. It is recommended that hospitals and medical record officers provide regular training or coaching to officers. And to health workers, especially medical records, in order to maintain the confidentiality of patient medical record information and carry out the established procedures properly.                   

scholarly journals PENGARUH KELENGKAPAN PENGISIAN FORMULIR TRANSFER PASIEN INTERNAL TERHADAP MUTU REKAM MEDIS

2021 ◽  
Vol 10 (2) ◽  
pp. 124-131
Author(s):  
Indar Farwanti Wahyuni
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Random Sampling ◽  
Health Workers ◽  
Sampling Technique ◽  
Simple Random Sampling ◽  
Patient Transfer ◽  
Literature Study ◽  
Number Of Patients

Abstract Internal patient transfer is the process of transferring patients from one room to another in a hospital while still being oriented towards quality and patient safety. The results of the observations showed that the filling of the internal patient transfer form was not optimal so that there were still incomplete forms due to the large number of patients and the weak coordination between health workers. To determine the effect of the completeness of filling out the internal patient transfer form on the quality of medical records. The research method used is quantitative with a descriptive approach. Data collection techniques used are observation, questionnaires and literature study. The sampling technique was simple random sampling technique so as to obtain a sample of 91 internal patient transfer forms. From the results of observations, 22% of the internal patient transfer forms were found that were not completely filled in, especially in the signature and clear name. The two variables have a strong relationship. The effect of the variable completeness of the internal patient transfer form on the medical record quality variable is 90.1% and the remaining 9.9% is influenced by other factors. Based on these studies, it can be concluded that the lack of accuracy and coordination of nurses, doctors and other officers in filling out internal patient transfer forms so that this affects the quality of medical records in the aspect of accuracy. Keyword : Completeness, Internal Patient Transfer Form, Medical Record Quality   Abstrak Transfer pasien internal merupakan proses pemindahan pasien dari satu ruangan ke ruangan yang lain di dalam satu rumah sakit dengan tetap berorientasi pada mutu dan keselamatan pasien. Hasil observasi menunjukkan bahwa belum optimalnya pengisian formulir transfer pasien internal sehingga masih terdapat formulir yang tidak lengkap disebabkan oleh faktor dari banyaknya pasien dan lemahnya koordinasi antara tenaga kesehatan. Untuk mengetahui pengaruh kelengkapan pengisian formulir transfer pasien internal terhadap mutu rekam medis. Metode penelitian yang digunakan yaitu kuantitatif dengan pendekatan deskriptif. Teknik pengumpulan data yang digunakan adalah observasi, kuesioner dan studi pustaka. Teknik pengambilan sampel adalah teknik simple random sampling sehingga memperoleh sampel sebanyak  91 formulir transfer pasien internal. Dari hasil observasi ditemukannya formulir transfer pasien internal yang belum terisi lengkap sebanyak 22% terutama pada tandatangan dan nama jelas. Kedua variabel memiliki hubungan yang kuat. Pengaruh variabel kelengkapan formulir transfer pasien internal terhadap variabel mutu rekam  medis sebesar 90,1% dan sisanya 9,9% dipengaruhi oleh faktor lain. Berdasarkan penelitian tersebut dapat disimpulkan bahwa kurangnya ketelitian dan koordinasi perawat, dokter dan petugas lain dalam pengisian formulir transfer pasien internal sehingga hal ini mempengaruhi mutu rekam medis pada aspek keakuratan. Kata kunci: Kelengkapan, Formulir Transfer Pasien Internal, Mutu Rekam Medis

scholarly journals REKAM MEDIS: PENGGUNAAN INFORMASI MEDIS PASIEN DALAM PELAKSANAAN ASAS PERLINDUNGAN PUBLIK

2020 ◽  
Vol 6 (2) ◽  
pp. 399-423
Author(s):  
Yudi Yasmin Wijaya ◽  
Edy Suyanto ◽  
Fanny Tanuwijaya
Keyword(s):  
Law Enforcement ◽  
Medical Record ◽  
Public Interest ◽  
Medical Records ◽  
Health Workers ◽  
Medical Condition ◽  
Privacy Rights ◽  
Confidential Information ◽  
The Public

Medical records contain confidential information of patient’s medical condition and treatment given.  In the public interest or for the sake of law enforcement, the confidentiality of medical records may be breached.   Stake holders (patients, health workers and law enforcers) should take cognizance of what procedures and limitation exist when requesting the acquisition of medical records in the public interest. Using a juridical doctrinal method, the prevailing rules and regulation related to medical record and its breach of confidentiality shall be analysed.  One important finding is that there is a dire need to seek a balance between satisfying public interest and the protection of patient’s privacy rights.

scholarly journals SOSIALISASI TEKHNIK PENGHITUNGAN KEBUTUHAN RAK REKAM MEDIS PADA PUSKESMAS ALAI KOTA PADANG

2020 ◽  
Vol 4 (2) ◽  
pp. 87
Author(s):  
Yanti Desnita Tasri
Keyword(s):  
Health Service ◽  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Health Care Services ◽  
Health Record ◽  
Care Services ◽  
Optimal Health ◽  
Service Activity ◽  
Storage Place

Puskesmas merupakan fasilitas pelayanan Kesehatan tingkat pertama yang dapat membantu mewujudkan derajat kesehatan yang optimal serta memiliki peran penting dalam pelaksanaan rekam medis (Kepmenkes RI, 2009). Puskemas Alai merupakan salah satu sarana pelayanan kesehatan di Kota Padang. Puskesmas Alai dalam memberikan layanan asuhan Kesehatan kepada masyarakat selalu menggunakan berkas rekam medis sebagai tempat penyimpan informasi pasien. Berdasarkan Permenkes No.269/MENKES/PER/III/2008 Tentang Rekam Medis maka dinyatakan rekam medis adalah berkas yang berisi catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain yang telah diberikan kepada pasien. Berkas rekam medis tersebut harus dapat disimpan dengan baik agar Ketika dibutuhkan lagi bisa didapatkan dengan efektif dan efisien dan kemanan berkas rekam medis tersebut bisa terjaga dengan baik. Untuk penyimpanan berkas rekam medis agar sesuai dengan standar yang sudah ditentukan maka dibutuhkan rak penyimpanan yang mampu menyimpan semua berkas rekam medis. Menurut Internasional Federation of Health Record Organization (IFHRO) kebutuhan rak rekam medis dapat dianalisis. Berdasarkan paparan tersebut maka Kegiatan Pengabdian Kepada Masyarakat (PKM) ini merupakan sosialisasi tentang metode analisa penghitungan kebutuhan rak rekam medis di Puskesmas Alai. Hasil dari kegiatan sosialisasi ini adalah dapat digunakan sebagai masukan bagi bagian rekam medis dalam kegiatan pengadaan kebutuhan rak rekam medis pada Puskesmas Alai Padang. Kata kunci: Rekam medis, Rak, Penyimpanan, Puskesmas, Tekhnik ABSTRACT Puskesmas is a first level health service facility that can help achieve optimal health status and has an important role in the implementation of medical records (Kepmenkes RI, 2009). Puskemas Alai is one of the health service facilities in Padang City. Puskesmas Alai in providing health care services to the community always uses medical record files as a storage place for patient information. Based on Permenkes No.269 / MENKES / PER / III / 2008 concerning Medical Records, it is stated that a medical record is a file containing notes and documents about patient identity, examination, treatment, actions and other services that have been provided to patients. The medical record files must be able to be stored properly so that when needed again they can be obtained effectively and efficiently and the safety of the medical record files can be maintained properly. For storing medical record files to conform to predetermined standards, a storage rack is needed which can store all medical record files. According to the International Federation of Health Record Organization (IFHRO) the need for medical record racks can be analyzed. Based on this explanation, this Community Service Activity (PKM) is a socialization of the analysis method for calculating the need for medical record racks at Alai Public Health Center. The results of this outreach activity can be used as input for the medical record section in the procurement of medical record racks at Alai Padang Health Center. Keywords: Medical Records, Shelves, Storage, Health Center, Technique

scholarly journals Tinjauan Literatur: Faktor-Faktor Penyebab Kelengkapan Pengisian Rekam Medis Rawat Inap Rumah Sakit

2020 ◽  
Vol 3 (2) ◽  
pp. 46-52
Author(s):  
Putu Adiz Siwayana ◽  
Ika Setya Purwanti ◽  
Putu Ayu Sri Murcittowati
Keyword(s):  
Quality Of Service ◽  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Medical Personnel ◽  
Google Scholar ◽  
Incomplete Filling ◽  
Evaluation And Monitoring

Every health facility, whether it is primary, secondary, tertiary, is required to maintain medical records in order to achieve administrative order. Incomplete (incomplete) medical records will affect the service process provided by health workers and have an impact on the quality of service of a hospital. This study aims to determine the factors causing the incomplete filling of inpatient medical records. This study uses a literature review method. The strategy in searching literature reviews is using Google Scholar. In the search phase, articles are limited to publications from 2015-2020. The keywords used are the factors causing incomplete medical record filling. The search results obtained 10 articles and then 5 articles were taken. The results of the literature review show that the factors causing the incompleteness of filling in medical records as a whole can be seen from the lack of knowledge, motivation and awareness of medical personnel about medical records. The meeting as a means of communication between caregivers and management has not yet been implemented to discuss evaluation and monitoring as well as sanctions for officers who do not complete medical records. lack of socialization on filling out medical records. Unsystematic arrangement of medical record forms. Limited availability of funds or budget to support medical record service activities. Conclusion Hospitals need to pay attention to the factors causing the incompleteness of filling in medical records so that filling in medical records is complete according to standards. So that the quality of service, especially the quality of patient medical records.AbstrakSetiap fasilitas kesehatan baik tingkat primer, sekunder, tersier wajib menyelenggarakan rekam medis agar tercapainya tertib administrasi. Ketidaklengkapan (Incomplete) rekam medis akan berpengaruh terhadap proses pelayanan yang diberikan oleh petugas kesehatan dan berdampak pada kualitas pelayanan suatu rumah sakit. Penelitian ini bertujuan untuk mengetahui faktor penyebab ketidaklengkapan pengisian rekam medis rawat inap. Penelitian ini menggunakan metode literatur review. Strategi dalam pencarian literatur review menggunakan Google Scholar. Pada tahap pencarian artikel dibatasi terbitan dari tahun 2015-2020. Kata kunci yang digunakan adalah Faktor Penyebab ketidaklengkapan pengisian rekam medis. Hasil penelusuran artikel didapatkan 10 artikel dan selanjutnya diambil 5 artikel. Hasil dari literatur review didapatkan faktor penyebab ketidaklengkapan pengisian rekam medis secara keseluruhan, penyebabnya dapat dilihat dari kurangnya pengetahuan, motivasi dan kesadaran dari petugas rekam medis tentang rekam medis. Belum terlaksananya rapat sebagai wadah komunikasi antara pemberi asuhan dan manajemen yang membahas evaluasi dan monitoring serta sanksi bagi petugas yang tidak mengisi rekam medis dengan lengkap. kurangnya sosialisasi pengisian rekam medis. Susunan formulir rekam medis yang tidak sistematis. Terbatasnya ketersediaan dana atau anggaran untuk mendukung kegiatan pelayanan rekam medis. Kesimpulan Rumah sakit perlu memperhatikan  faktor penyebab ketidaklengkapan pengisian rekam medis sehingga pengisian rekam medis menjadi lengkap sesuai dengan standar. Sehingga  mutu dari pelayanan terutama mutu rekam medis pasien.

Criminal Liability for Misuse of Electronic Medical Records in Health Services

SOEPRA ◽  
2020 ◽  
Vol 5 (2) ◽  
pp. 215
Author(s):  
Prilian Cahyani ◽  
Astutik Astutik
Keyword(s):  
Health Services ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Practice ◽  
Medical Records ◽  
Health Workers ◽  
Criminal Liability ◽  
Medical Personnel ◽  
Conceptual Approach

Electronic medical records (RME) have been used in hospitals as a substitute for or complementary to medical records in the form of paper. The obligation to make medical records is the responsibility of every doctor or dentist in carrying out the medical practice. However, the use of electronic-based medical records does not rule out the possibility of raising problems in the field of law, if some abuse it. This will raise the issue of who has the obligation to take responsibility. The problem is the background of the author to write in an article with the title "Accountability for the Misuse of Electronic Medical Record Abuse in Health Services". The formulation of the problem in this article is: 1) Setting an electronic medical record; 2) Criminal liability for the misuse of electronic medical records. The research method used is normative legal research with a statutory approach and a conceptual approach. From the discussion, it can be seen that in Indonesia the obligation to make medical records is specifically regulated in the Medical Practice Law. Furthermore, in the Ministry of Health No. 269 / MENKES / PER / III / 2008 especially Article 2 paragraph 2 states that medical records can be made electronically. However, to date, no specific regulations are governing electronic medical records. The use of electronic systems in medical records makes it necessary to heed the provisions of Law No. 11 of 2008 concerning Electronic Information and Transactions. The party who has the responsibility for the misuse of the Electronic Medical Record covers people who in this case are medical personnel or certain health workers. Hospitals can also be held responsible for the misuse of electronic medical records.

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