Legal Consistency of Health Personnel in Making Medical Records

Abstract

Medical record is a record or document containing patient identity, examination, treatment, action, and other services that must be made by health workers, but not 100% complete medical records. Currently, when talking about medical records, doctors always think that in the law on health workers, medical records must be made by health workers. Purpose/Objective Study:To analyze the legal consistency of health workers in making medical records. Design/Methodology/Approach: This research method is a normative combination of library studies with deductive research analysis. Findings: The results of patient records carried out by the medical profession are called medical records, patient records carried out by nurses are called nursing care documentation, and patient records carried out by midwives are called midwifery care documentation. Doctors who do not make medical records can get criminal sanctions, while nurses and midwives will get administrative sanctions if they do not do documentation of care. There is a consistency of laws that require doctors, dentists, nursing, and midwives to make medical records, albeit in different terms. There has been no consistency of laws governing sanctions between doctors, dentists, nurses, and midwives. Further study is needed to evaluate the legal products governing sanctions for health workers who do not make medical records.