scholarly journals REKAM MEDIS SEBAGAI ALAT BUKTI DALAM PENYELESAIAN SENGKETA LAYANAN MEDIS

Yurispruden ◽  
2020 ◽  
Vol 3 (1) ◽  
pp. 61
Author(s):  
Abdul Rokhim
Keyword(s):  
Medical Record ◽  
Expert Testimony ◽  
Medical Records ◽  
Criminal Procedure ◽  
Medical Services ◽  
Dual Function ◽  
Procedure Code ◽  
Written Form

AbstrakRekam medis adalah berkas yang berisi catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain yang telah diberikan kepada pasien. Secara formil, rekam medis sebagai alat bukti dalam penyelesaian sengketa layanan medis mempunyai fungsi ganda, yaitu sebagai alat bukti keterangan ahli dalam bentuk tertulis berdasarkan pasal 186 dan 187 Undang-undang Nomor 8 Tahun 1981 tentang Acara Pidana (KUHAP), dan sebagai alat bukti surat berdasarkan pasal 187 KUHAP. Secara materiil, kedudukan rekam medis sebagai alat bukti keterangan ahli maupun sebagai alat bukti surat merupakan alat bukti bebas, artinya hakim tidak terikat untuk meyakini kebenaran isi rekam medis, ia bisa meyakini dan menggunakan alat bukti itu atau tidak, sepenuhnya bergantung pada penilaian bebas dari hakim.Kata Kunci: Rekam Medis; Alat Bukti; Layanan Medis AbstractMedical record is a file that contains records and documents about the patient's identity, examination, treatment, actions and other services that have been provided to patients. Formally, medical records as evidence in resolving disputes in medical services have a dual function, namely as evidence of expert testimony in written form pursuant to articles 186 and 187 of Law Number 8 of 1981 concerning Criminal Procedure (KUHAP), and as evidence of letters based on article 187 of the Criminal Procedure Code. Materially, the position of the medical record as evidence of expert statements and as evidence of letters is free evidence, meaning that the judge is not bound to believe the truth of the contents of the medical record, he can believe and use the evidence or not, entirely dependent on the free assessment of the judge.Keywords: Medical Record; Evidence; Medical Services

MEDICAL RECORD KEEPING; AN UPDATE

2019 ◽  
Vol 3 (7) ◽  
Author(s):  
Dr. Naveen Gupta ◽  
Dr. R. K. Choubey
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Medical Profession ◽  
Legal Profession ◽  
Consent Form ◽  
Medical Services ◽  
Record Keeping ◽  
Legal Guidelines ◽  
Legal Consequences

Now a day’s Medical Profession not only deals with Medical affairs it involves various aspects of Legal Profession as well. Hence it should be re- coined as Medico Legal Profession. While providing any medical services if any issue arises then Doctors has to face the legal consequences and brought under the court jurisdiction for prosecution like other criminals.  The only thing which helps in front of court is the documents produced by the treating doctor, so keeping the Medical Records in meticulous manner,  maintaining it & keeping it safe is very important. So one should be very particular while recording the details & vitals in OPD Card, Bed Head ticket, Consent Form, Admission & Discharge Ticket of the patients. Doctors should be well aware of the things to be recorded into Medical Records, as well more aware about how to keep the records & to produce them when demanded in a Legitimate manor. Keywords: Medical Records, Record Keeping, Medico legal, Guidelines, Legetimate

scholarly journals VALIDITAS KETERANGAN AHLI DARI PENYIDIK DALAM PEMBUKTIAN KASUS UJARAN KEBENCIAN RAS DI MEDIA SOSIAL (STUDI PUTUSAN: NO.1105/PID.SUS/2017/PN JKT.UTR)

2018 ◽  
Vol 1 (1) ◽  
pp. 839
Author(s):  
Hendra . ◽  
Dian Andriawan Daeng Tawang
Keyword(s):  
Research Methods ◽  
Expert Testimony ◽  
Criminal Procedure ◽  
Criminal Case ◽  
Legal Research ◽  
Procedure Code ◽  
Pros And Cons ◽  
Special Expertise ◽  
Conducting Research

Expert’s Testimony is the information of a person who has special expertise for the purpose of examination in a criminal case and must be given in court. An expert must provide information for justice, as well as possible and according to knowledge in his area of expertise. The expert's testimony from the police is still questionable on the independence and justice of the defendant, the expert must be independent and fair in giving explanation there should be no influence from internal or external parties. There are still many expert testimonies from investigators who are highly doubtful of their independence and deemed inappropriate to be made expertly by academicians, but in the Criminal Procedure Code it is not clear whether the expert's testimony from the investigator is allowed or not. Therefore the author interested in conducting research related to the validity of expert testimony from investigators. The author conducted research with normative legal research methods supported by interviews are expected to help answer the research and the source of interviewed is from the academics and practitioners. In the absence of clear rules, the expert's testimony from the investigator will be the pros and cons but if it refers to the understanding and the main purpose of expert testimony in the Criminal Procedure Code, it is unlikely that the expert's expertise is allowed because it will not be free, independent.

Faktor-Faktor yang Mempengaruhi Mutu Pelayanan Rekam Medis di Rumah Sakit

2019 ◽  
Vol 14 (2) ◽  
pp. 59
Author(s):  
Rindi Rendarti
Keyword(s):  
Service Quality ◽  
Human Resources ◽  
Medical Record ◽  
Medical Records ◽  
Services Quality ◽  
Medical Services ◽  
Quality Of Services ◽  
Hospital Services ◽  
Incomplete Filling

Background: Medical record units as part of supporting medical services in hospitals have an important role in improving the quality of services in hospitals. The indicator of service quality in hospital is measured by incomplete inpatient medical record files. Based on several studies in various hospitals, the complete of inpatient medical record files is around 70% - 80% from 100%. Based on the preliminary data in action research in PKU Muhammadiyah hospital, there were 60 % incomplete in filling the medical resume from 100% target. There are many things that occurred, one of them are about human resources that is affected by behavior, the implementation of operational standards in filling medical records, punish and reward files. Objective: To review the factors that affect the quality of service in medical record units related to improving the quality of hospital services.  Methods: the method of this study used relevant health databases including Scholars by using a combination of  terms: hospital service quality indicators, incompleteness in filling medical medical records, quality of medical record services. Results: The result of this study said that there were related between medical record services and quality of hospital services. The quality indicator in the medical record can be able to be measured was the number of incomplete filling in medical record files. Filling of incomplete medical record files has the potential to reduce the overall quality of hospital services Keywords: quality of medical record services, quality of hospital medical services, incomplete medical record filling

scholarly journals Identifikasi Prioritas Masalah Unit Rekam Medis di Puskesmas Nusukan

2020 ◽  
Vol 3 (1) ◽  
pp. 24-28
Author(s):  
Puguh Ika Listyorini
Keyword(s):  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Group Discussion ◽  
Multiple Criteria ◽  
Medical Services ◽  
Utility Assessment ◽  
Descriptive Research ◽  
Workforce Needs

Health services consist of two kinds, namely medical and non-medical services. One of the non-medical services provided by the medical record unit. In providing medical record unit services do not always run well, therefore it is necessary to identify the priority determination of the problem to find out what problems must be solved first. The Multiple Criteria Utility Assessment (MCUA) method is a method of determining priority problems with scoring techniques. The purpose of this study was to determine the priority of problems in the medical record unit of the Nusukan Health Center using the MCUA Method. This research uses descriptive research design with 4 speakers. According to the results of the identification of problems carried out by the Group Group Discussion (FGD) that there are 3 problems in the medical record unit of the Nusukan Public Health Center, namely the lack of resources for medical records, medical record documents, and the availability of rooms for managing medical records that are still limited. The priority problem with the MCUA method shows that the problem with the highest value is the lack of medical record personnel. Before making additional workforce, it is recommended to calculate the workforce needs in the medical record unit according to the workload of the medical record officer so that the additional workforce is in accordance with the workload of the officer.AbstrakPelayanan kesehatan terdiri dari dua macam yaitu pelayanan medis dan non medis. Pelayanan non medis salah satunya diberikan  oleh unit rekam medis.  Dalam memberikan pelayanan unit rekam medis tidak selalu berjalan dengan baik, oleh karena itu perlu dilakukan identifikasi penentuan prioritas masalah untuk mengetahui masalah apa saja yang harus diselesaikan terlebih dahulu. Metode Multiple Criteria Utility Assessment (MCUA) adalah salah satu metode penentuan prioritas masalah dengan tekhnik scoring. Tujuan penelitian ini untuk mengetahui prioritas masalah di unit rekam medis Puskesmas Nusukan menggunakan Metode MCUA. Penelitian ini menggunakan desain penelitian deskriptif dengan 4 orang narasumber. Menurut hasil identifikasi masalah yang dilakukan dengan Forum Group Discussion (FGD) bahwa terdapat 3 masalah di unit rekam medis Puskesmas Nusukan, yaitu kurangnya sumber daya tenaga rekam medis, missfile dokumen rekam medis, dan ketersediaan ruagan untuk penggelolaan rekam medis yang masih terbatas. Prioritas masalah dengan metode MCUA menunjukkan masalah dengan nilai paling tinggi adalah kurangnya sumber daya tenaga rekam medis. Sebelum melakukan penambahan tenaga kerja, maka disarankan agar menghitung kebutuhan tenaga kerja di unit rekam medis menurut beban kerja petugas rekam medis agar penambahan tenaga kerja sesuai dengan beban kerja petugas.

Perencanaan Arsitektur Sistem Informasi Rekam Medis dan Monitoring Gizi Buruk Berbasis Cloud Computing (Studi Kasus: Dinas Kesehatan Propinsi Jawa Barat)

2017 ◽  
Vol 8 (3) ◽  
Author(s):  
Ova Nurisma Putra
Keyword(s):  
Cloud Computing ◽  
Information System ◽  
Medical Record ◽  
Medical Records ◽  
Monitoring And Evaluation ◽  
Open Group ◽  
Development Method ◽  
Information System Architecture ◽  
Architecture Framework ◽  
Architecture Development

Abstract. West Java Provincial Health Office still faces difficulties in managing information, especially in medical records. Recording and reporting of malnutrition are still done in some stages starting from collecting data from village midwives, puskesmas, Regency/City Health Office then Provincial Health Office and forwarded to the the central office. It is necessary to manage information through service system by utilizing Cloud Computing based on information technology. This research uses The Open Group Architecture Framework (TOGAF) approach in Architecture Development Method (ADM), from Architecture Capability Iteration to  Architecture Development Iteration. Monitoring and Evaluation (M & E) are two integrated activities in the context of controlling a program. The results of this research are planning a medical record information system architecture and monitoring malnutrition based on Cloud Computing with the name of M2Rec (Medical Record and Monitoring) in the form of integrated recommendation and development between current information system and proposed information system architecture.Keywords: togaf adm, medical record and monitoring, cloud computing Abstrak. Perencanaan Arsitektur Sistem Informasi Rekam Medis dan Monitoring Gizi Buruk Berbasis Cloud Computing. Dinas Kesehatan Propinsi Jawa Barat masih mengalami kesulitan dalam pengelolaan informasi yang baik, terutama pada proses rekam medis, pencatatan dan pelaporan gizi buruk masih dilakukan secara bertingkat mulai pengumpulan data dari bidan desa, puskesmas, Dinas Kesehatan Kabupaten/Kota kemudian Dinas Kesehatan Propinsi dan diteruskan ke pusat. Sehingga perlu diupayakan pengelolaan informasi melalui sistem pelayanan dengan memanfaatkan teknologi informasi berbasis Cloud Computing. Penelitian ini menggunakan pendekatan framework The Open Group Architecture Framework (TOGAF) Architecture Development Method (ADM), yaitu iterasi ke satu pada Architecture Capability Iteration daniterasi ke dua pada Architecture Development Iteration. Monitoring dan Evaluasi (M&E) merupakan dua kegiatan terpadu dalam rangka pengendalian suatu program. Hasil dari penelitian ini adalah perencanaan arsitektur sistem informasi rekam medis dan monitoring gizi buruk berbasis Cloud Computing dengan nama M2Rec (Medical Record and Monitoring) yang berupa rekomendasi integrasi dan pengembangan antara sistem informasi berjalan saat ini dengan arsitektur sistem informasi yang diusulkan.Kata kunci: togaf adm, medical record and monitoring, cloud computing.

Analisis Unsur Manajemen dalam Pengolahan Rekam Medis di Rumah Sakit TNI AU Lanud Roesmin Nurjadin

2018 ◽  
Vol 1 (1) ◽  
pp. 20-25
Author(s):  
Henny Maria Ulfa
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Processing Method ◽  
Qualitative Approach ◽  
Check List ◽  
Training Material ◽  
Patient Medical Record ◽  
Qualitative Descriptive ◽  
Material Element ◽  
Descriptive Method

Hospitals must conduct a medical record activities according to Permenkes NO.269 / MENKES / PER / III / 2008 about Medical Record, to achieve the purpose of medical record processing required 5 management elements are: man, money, material, machine, and method. The medical record processing that has been implemented at the Hospital TNI AU LANUD Roesmin Nurjadin that is coding, coding only done for BPJS patients whose conducted by the officer with education background of D3 nursing, it be impacted to the storage part is wrong save and cannot found patient medical record file because are not returned. The purpose of this research is to know the element of management in the processing of medical records at the Hospital TNI AU LANUD Roesmin Nurjadin. This research is done by Qualitative descriptive method, Qualitative approach, instrument of data collection of interview guidance, observation guidance, check list register, and stationery, number of informant 6 people with inductive way data analysis. The result of this research found that Mans elements only amounts to 2 people so that officers work concurrently and have never attended training, material element and machines elements of medical record processing not yet use SIMRS and tracer, while processing method elements follow existing habits and follow the policy of hospital that is POP organization. Keywords: Management elements, medical record processing

scholarly journals Automatic Placement of Genomic Research Results in Medical Records: Do Researchers Have a Duty? Should Participants Have a Choice?

2015 ◽  
Vol 43 (4) ◽  
pp. 827-842
Author(s):  
Anya E.R. Prince ◽  
John M. Conley ◽  
Arlene M. Davis ◽  
Gabriel Lázaro-Muñoz ◽  
R. Jean Cadigan
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Genomic Research ◽  
Research Results ◽  
Research Participants ◽  
Difficult Question ◽  
Automatic Placement ◽  
Study Participants ◽  
Research Studies

The growing practice of returning individual results to research participants has revealed a variety of interpretations of the multiple and sometimes conflicting duties that researchers may owe to participants. One particularly difficult question is the nature and extent of a researcher’s duty to facilitate a participant’s follow-up clinical care by placing research results in the participant’s medical record. The question is especially difficult in the context of genomic research. Some recent genomic research studies — enrolling patients as participants — boldly address the question with protocols dictating that researchers place research results directly into study participants’ existing medical records, without participant consent. Such privileging of researcher judgment over participant choice may be motivated by a desire to discharge a duty that researchers perceive themselves as owing to participants. However, the underlying ethical, professional, legal, and regulatory duties that would compel or justify this action have not been fully explored.

Maximum Duration of the Measures of Remand Detention in Custody and House Arrest in Criminal Cases

De Jure ◽  
2019 ◽  
Vol 10 (2) ◽  
Author(s):  
Ekaterina Salkova ◽  
◽  
Yanko Roychev ◽  
Keyword(s):  
Criminal Procedure ◽  
Criminal Cases ◽  
House Arrest ◽  
Maximum Duration ◽  
Procedure Code ◽  
Maximum Period

The maximum duration of the detention in custody and house arrest measures in criminal cases is researched. A number of issues have been considered regarding the calculation of the term and its initial and final moments, including the hypotheses related to the returning of the case to the prosecutor by the court, the taking of the measures against an accused party detained on different grounds, as well as in view of a modification of the legal qualification of the indictment, establishing a different maximum duration under Art. 63, para. 4 of the Criminal Procedure Code. An emphasis has been placed on the disputable aspect of the duration of the period in regard to underage accused parties. A necessity to introduce a maximum period of detention in custody and house arrest,including also the court phase of the trial, has been acknowledged.

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