Abstract

Nurses as health workers in carrying out their duties and professions often face what appears to be malpractice, namely in the form of medical disputes. The dispute is filed with a criminal or civil suit which leads to the process of examining the case in court. In the case of examination, the evidence is required under legal provisions. One of the pieces of evidence is medical records as documentary evidence. The provision that medical records can be used as evidence is Permenkes No. 269 / MENKES / PER / III / 2008 concerning Medical Records. In criminal law, to prove it adheres to the principle of proof of law negatively, which seeks material truth, not formal truth as medical record evidence so that the position of medical record evidence needs to be equipped with other evidence, and it must be with the conviction of a judge. Whereas civil law it is looking for formal truth, meaning that only sufficient evidence requires written evidence. Medical records can be used as evidence for both patients and doctors, nurses, and health service providers at court case examinations, because medical records contain who, when, how, the medical action took place. Medical records as a means of legal protection at least provide legal assurance and certainty to uphold law and justice. This study aims to examine juridically medical records as a means of legal protection for nurses. The approach used in this research is a statutory approach and a conceptual approach.

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