Legal Analysis of Medical Record Documents on the Protection of Patient Rights

Abstract

Hospitals and medical personnel have the main goal, namely to provide the maximum possible treatment and care for the patient's recovery. whether inpatients, outpatients or emergency patients, a medical record must be made for each patient. The hospital will be responsible for protecting the information contained in medical records against the possibility of loss of information, falsification of data. The method applied by the author in writing this thesis is the Sociological Juridical legal research method, meaning that this method will examine community behavior that arises as a result of interactions with the existing norm system. There is. Standards for completeness of medical record documents at RSUD Dr. Loekmono Hadi Kudus, namely the file starting from the time, day, date must all be filled in. If any file is incomplete, it will be returned to the data collection officer. In this case, it is related to the theory of legal certainty because this theory contains legal principles which must be clear to people who obey the law, so that people can adjust their actions to existing regulations. The use of medical information requires careful management of the information contained therein. It is necessary to pay attention to the use of medical records because the medical information contained therein has the potential to be sensitive for patients. In this case it is related to the theory of legal protection because it is related to consumer protection law. By using this theory, it can be seen that there are regulations regarding patient rights and if there is a violation by the hospital or doctor, the patient can take legal action.