KERAHASIAAN REKAM MEDIS DI RUMAH SAKIT AVECIENA MEDIKA MARTAPURA

Abstract

Medical records are managed by procedures and standards and policies of the organization. Information on identity, diagnosis, history of disease, history of examination, and patient medical history are kept conidential by doctors, dentists, health workers, management oficers and leaders of health care facilities. This study aims to provide an overview of conidentiality and medical record request process at the Medical Record Unit of Aveciena Medika Hospital. The research method used is descriptive qualitative method. The data collection process was done by observation and interview to the oficer of Medical Record Work Unit for 3 people. Result: the implementation of medical record conidentiality is an unwritten agreement, by using oath to medical recorder, doctor, dentist in stored medical record ile. In the request of medical records relating to legal aspects, institutions or institutions of the insurer, and the interests of the patient, medical records can not be borrowed or taken out but are allowed to borrow copies of copies of resumes provided that there is a cover letter from the court or the insurer and make written permission. Conclusion. Medical Record Work Unit does not yet have a comprehensive medical records conidentiality policy and is still implemented in small units in terms of illing room permit. Requests for medical information should be preceded by making written permission addressed to the leader of the health service facility