EVALUATION OF FORMAT AND SECURITY OF DENTAL ELECTRONIC MEDICAL RECORD SYSTEMS IN GENERAL HOSPITAL BASED ON LEGISLATION

Erdianto Setya Wardhana*  -  Faculty of Dentistry Gadjah Mada University Yogyakarta, Indonesia
Suryono Suryono  -  Faculty of Dentistry Gadjah Mada University Yogyakarta, Indonesia, Indonesia
Ari Hernawan  -  Faculty of Law Gadjah Mada University Yogyakarta, Indonesia, Indonesia
Lukito Edi Nugroho  -  Faculty of Engineering Gadjah Mada University Yogyakarta, Indonesia, Indonesia

(*) Corresponding Author

Background: Electronic medical records in dentistry are the latest implementation in the health sector, especially dental health history to the services needed by patients by health care facilities and affect the format of dental, medical records and electronic medical record security systems. This study aimed to review the completeness of the medical record format and the electronic medical record security system of the dental polyclinic of the General Hospital in Batam City.
Method: This study used a descriptive cross-sectional observational design with two samples. Processing data in the form of tables and texts and conclusions as a result of research.
Result: The results showed incomplete dental electronic medical record formats at hospital A, such as patient identity, required medical data, odontogram, intraoral examination, and treatment chart, while Hospital B included patient identity, required medical data, intraoral analysis, treatment chart, and appendix. The two samples did not meet the integrity and non-repudiation aspects of the electronic medical record security system.
Conclusion: According to the Indonesian Dental Medical Record Guidelines, both samples have an incomplete dental electronic medical record format and security system.

Keywords: Dental electronic medical record, Complete format, Security system

  1. Kemenkes RI. Panduan Rekam Medis Kedokteran Gigi. 2015. 70 p.
  2. Murniwati M. Peran Rekam Medik Gigi Sebagai Sarana Identifikasi, Majalah Kedokteran Andalas. 2012;36(2):163.
  3. Karimah RN, Nurmawati I. Kualitas Informasi Terkait Penerapan Hasil Desain Rekam Medis Gigi Di Klinik Sakinah Kabupaten Jember. J Ilm Inov. 2016;16(2):109–15.
  4. Nugraheni SW. Aspek Hukum Rekam Medis Elektronik di RSUD Dr Moewardi. 2018;1:92–7.
  5. Budiyanti RT, Herlambang PM, Nandini N. Tantangan Etika dan Hukum Penggunaan Rekam Medis Elektronik dalam Era Personalized Medicine. J Kesehat Vokasional. 2019;4(1):49.
  6. Ningtyas AM, Lubis IK. Literatur Review Permasalahan Privasi Pada Rekam Medis Elektronik. Pseudocode. 2018;5(2):12–7.
  7. Samandari NA, Chandrawila S W, Rahim AH. Kekuatan Pembuktian Rekam Medis Konvensional Dan Elektronik. Soepra. 2016;2(2):154–64.
  8. Erawantini F, Nugroho E, Sanjaya GY, Hariyanto S. Rekam Medis Elektronik: Telaah Manfaat dalam Konteks Pelayanan Kesehatan Dasar. 2013;1(1):1–10.
  9. Liu K, Acharya A, Alai S, Schleyer TK. Using Electronic Dental Record Data for Research: A Data-mapping Study. J Dent Res. 2013;92(May 2013):S90–6.
  10. Komisi Akreditasi Rumah Sakit. Instrumen survei. Instrumen Survei Standar Nas Akreditasi Rumah Sakit Ed 1. 2018;
  11. Joint Commision International. Joint Commission International Standar Akreditasi Rumah Sakit. Standar Akreditasi Rumah Sakit. Jt Commision Int Ed 5. 2014;(April).
  12. Agung Prasetya Gunawan. Gambaran Rekam Medis Gigi Puskesmas Bahu Kota Manado Ditinjau dari Standar Nasional Rekam Medik Kedokteran Gigii. Jurnal e-GIGI. 2012;1, No 2:1–7.
  13. Trisnowahyuni ., Rahim AH, Doloksaribu EI. Rekam Medis Odontogram Sebagai Alat Identifikasi Dan Kepentingan Pembuktian Di Pengadilan. Soepra. 2017;3(1):117.
  14. Konsil Kedokteran Indonesia. Manual Rekam Medis-Konsil Kedokteran Indonesia. Buku Man Rekam Medis [Internet]. 2006;23.
  15. Sutandra L. Pengaruh Sistem Pengamanan Data Pasien di Rumah Sakit Menuju Era Revolusi Industri 4.0. J Heal Sci Physiother. 2019;1(2):106–14.

Lisensi Creative Commons
This work is licensed under a Lisensi Creative Commons Atribusi-BerbagiSerupa 4.0 Internasional.
Contact us: Odonto Dental Journal: Jl. Raya Kaligawe Km.4, PO BOX 1054/SM Semarang, Central Java, Indonesia, 50112. Email: odontodentaljournal@unissula.ac.id
apps