Abstract
Medical record information is confidential which must be protected from leakage of data/information in accordance with the medical code of ethics and applicable laws and regulations. The release of medical information must follow the applicable procedures, this aims to protect the hospital from further demands. This study aims to describe the suitability of SOPs for releasing medical information to third parties, types of requests for release of medical information and constraints in releasing medical information using fishbone diagrams. This research is a literature review study using a sample of 11 journals. Search articles using the Google Scholar database. The results of the study found that the percentage of compliance with SOPs for releasing medical information to third parties in hospitals was the percentage of releases that were in accordance with SOPs between 66%-82%, while the precentage that did not match the SOPs was between 18%-34%. The types of requests for release of medical information are for the purposes of visum et repertum, insurance and education. Constraints in releasing medical information to third parties in hospitals using fishbone diagrams are mostly found in Man, especially in patients/patient families do not bring complete requirements.
Highlights
Medical record information is confidential which must be protected from leakage of data/information in accordance with the medical code of ethics and applicable laws and regulations
The release of medical information must follow the applicable procedures, this aims to protect the hospital from further demands
This study aims to describe the suitability of SOPs for releasing medical information to third parties, types of requests for release of medical information and constraints in releasing medical information using fishbone diagrams
Summary
Berdasarkan penelitian, didapatkan jenis permintaan pelepasan informasi medis di rumah sakit yaitu untuk keperluan visum et repertum sebanyak 7 penelitian sehingga presentasenya sebesar 63%, asuransi sebanyak 5 penelitian sehingga presentasenya sebesar 45% dan pendidikan sebanyak 3 penelitian sehingga presentasenya sebesar 27%. Berdasarkan penelitian, kendala pelepasan informasi medis yaitu (1) Kendala pada Man adalah petugas rekam medis tidak mengecek kembali kelengkapan persyaratan, pasien/keluarga pasien tidak membawa persyaratan secara lengkap, pengisian formulir permintaan belum lengkap, pihak kepolisian meminta pemeriksaan visum dengan lisan, pihak kepolisian tidak selalu mengambil hasil visum, penyidik yang mengajukan permohonan visum tidak sesuai dengan persyaratan. Kendala dalam pelepasan informasi medis kepada pihak ketiga di rumah sakit dengan menggunakan diagram fishbone yang terbanyak terdapat pada Man terutama pada pasien/keluarga pasien tidak membawa persyaratan secara lengkap. Sehingga jenis permintaan pelepasan informasi tersebut sudah sesuai dengan PERMENKES RI No 269/MENKES/PER/III/2008 yang menjelaskan bahwa rekam medis dapat dibuka dalam hal untuk kepentingan kesehatan pasien, memenuhi permintaan aparatur penegak hukum dalam rangka penegakan hukum atas perintah pengadilan, permintaan dan/atau persetujuan pasien sendiri, permintaan institusi/lembaga berdasarkan ketentuan perundang-undangan, dan untuk kepentingan penelitian, pendidikan dan audit medis sepanjang tidak menyebutkan identitas pasien (Kemenkes, 2008)
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