Abstract
Objective: Hospitals are legally responsible for the excellent service quality provided to patients based on statutory provisions. Hospital responsibilities in health services include criminal, civil and administrative liability. This study aims to determine the responsibility of the hospital in documenting medical resumes. Methods: The research method used is literature review, through review of research journals related to the completeness of medical resumes that have been published on accredited journal platforms in 2010-2020. This research was conducted in August-October 2020. Results: Analysis of 20 research journals relating to the completeness of medical resumes in the reviewed hospitals, it is known that the completeness of medical resume documents in the hospital is on average 75.80% Only 2 hospitals out of 20 hospitals documented medical resumes in accordance with the minimum hospital service standards. Based on the prevailing laws and regulations, the hospital is not criminally responsible for the incomplete documentation of medical resume, but the hospital is responsible civilian based on the principle of representative responsibility and administratively. Conclusion: The hospital has not optimally documented medical resumes in accordance with the minimum hospital service standards. As a result, the hospital is both civilly and administratively liable. Supervision of the doctor's performance in documenting medical resumes and the role of the medical record committee in ensuring medical staff complete all medical records of patients served is required.
Highlights
Hospital is a health service institution providing complete individual health services for inpatient, outpatient and emergency services
Supervision of the doctor's performance in documenting medical resumes and the role of the medical record committee in ensuring medical staff complete all medical records of patients served is required
The results of the research selected are research examining the completeness of medical resume documentation or other terms, namely discharge summary
Summary
Hospital is a health service institution providing complete individual health services for inpatient, outpatient and emergency services. In carrying out its functions, the hospital has an obligation to document the medical records [1]. The definition of medical records in the Regulation of the Minister of Health Number 269 of 2008 concerning Medical Records is "Files containing notes and documents regarding patient identity, examination, treatment, actions and other services having been provided to patients"[2]. The hospital responsibility in the patient care and the documentation of patient medical records is delegated to doctors, nurses and health care professionals[3]. What stated in the paragraph (1) is that every doctor or dentist in carrying out medical practice is obliged to document medical records, and in the paragraph (2), it stated that medical records as referred to the paragraph (1) must be completed immediately after the patient has received health services [4]
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