Rekam Medis

01Definition and Legal Foundation

A medical record is a legal document that records the entire journey of healthcare services rendered to a patient. Under Permenkes No. 24/2022, it is defined as a document containing patient identity data, examination findings, diagnoses, treatments, procedures, and all other services provided. This document must be prepared in a complete and accurate manner.

The legal framework governing medical records in Indonesia rests on several pillars. Permenkes No. 24/2022 was enacted on August 31, 2022, and it revoked the older Permenkes 269/MENKES/PER/III/2008 about Medical Records. This newer regulation shifts the paradigm toward digitalization. The regulation does not only apply to large hospitals; it explicitly requires ALL healthcare facilities to implement Electronic Medical Records (RME), including hospitals (public and private), puskesmas, clinics (pratama and utama), independent physician practices, and laboratories.

Further reinforcing this obligation, PP No. 28/2024 states that every healthcare facility is required to maintain medical records (Pasal 777), and every physician and healthcare professional providing individual healthcare must create them. Medical records must be kept electronically in accordance with prevailing regulations. If a facility cannot maintain electronic records due to technical obstacles, non-electronic records may be used until those obstacles are resolved (Pasal 779).

The exam loves to test the mandatory nature of medical record creation. No physician is exempt. A solo practitioner in a remote area still must maintain medical records.

02Types and Minimum Content of Medical Records

Medical records are categorized by the type of service setting. Each has slightly different minimum content requirements. This is a frequently tested distinction.

Content Requirements by Service Type

Under Permenkes 24/2022, the minimum content of medical records consists of: (a) patient identity; (b) physical examination and supporting test results; (c) diagnosis, treatment, and follow-up plan.

For Electronic Medical Records (RME), the content is divided into administrative documentation (at minimum containing registration documentation) and clinical documentation (containing all healthcare service documentation).

Patient Registration Data is a critical concept. Patient identity data must at minimum include the medical record number, the patient's name, and the national identification number (NIK). Social data must at minimum include religion, occupation, education, and marital status.

The exam may ask: "What is the minimum data required for patient registration?" The answer is always medical record number, patient name, and NIK.

03Ownership and Confidentiality

This is the single most tested concept related to medical records. You must memorize the dual ownership principle.

The Dual Ownership Rule

The ownership of the medical record document and its content carries two meanings. First, the medical record document belongs to the healthcare facility. Therefore, the facility is responsible for any loss, damage, falsification, and/or unauthorized use of the medical record document. The second meaning is that the content of the medical record belongs to the patient, and may be conveyed to close family or other parties after obtaining the patient's consent.

Because the document belongs to the facility, the facility bears liability for loss, damage, or unauthorized access. Because the content belongs to the patient, the patient has the right to access their own medical information.

Confidentiality Rules

All healthcare professionals are obligated to maintain the confidentiality of the medical record, whether in written, verbal, or electronic form. According to Permenkes No. 24/2022, all parties involved in healthcare services at a facility must maintain the confidentiality of medical record content, even after the patient has died.

The phrase "even after the patient has died" is a classic exam trap. Many students incorrectly assume confidentiality obligations end with the patient's death.

Exceptions to Confidentiality (Conditions Allowing Disclosure)

Ministerial approval is required for opening medical record contents, with the exception of disclosures ordered by a court. Disclosure can be done by providing a copy of the medical record and/or displaying the original document.

For purposes of research, education, and medical audit, the authorized parties may access medical records as long as patient identity is not revealed, and all requests must be made in writing to the head of the healthcare facility.

The exam will test whether you know that court orders do not need Ministerial approval, while most other institutional requests do. Also, for research and education, the key discriminator is that patient identity must be de-identified.

04Retention Periods

This is another high-yield area. Pay attention to the difference between conventional (paper-based) and electronic records.

Retention Period Comparison Table

Electronic medical record data at healthcare facilities must be stored for a minimum of 25 years from the date of the patient's last visit. After that period, the electronic medical record data may be destroyed, except for data that is still being used or utilized.

Conventional medical records for inpatients must be stored for at least 5 years from the date the patient was last treated. After 5 years, the records may be destroyed, but the discharge summary and informed consent must be retained for up to 10 years.

The most commonly tested numbers are 5 years (inpatient paper record), 10 years (discharge summary/informed consent), and 25 years (electronic). The 2-year rule for non-hospital facilities is a less common but still testable point.

After the retention period expires, records may be destroyed, not must be destroyed, and only if the data is no longer being used.

05Electronic Medical Records (RME) and SATUSEHAT

The primary purpose of Permenkes 24/2022 is to transform medical record-keeping from a paper-based (analog) format to a standardized digital format known as Electronic Medical Records (RME).

Key Features of the RME System

The operational activities of an RME system include:

1. Patient Registration

2. Distribution of Electronic Medical Record Data

3. Clinical Information Entry

4. Medical Record Information Processing

5. Data Input for Billing Claims

6. Medical Record Storage

7. Quality Assurance of Medical Records

8. Transfer of Medical Record Content

The facility must ensure: complete and clear documentation of all actions performed; security, integrity, confidentiality, and availability of data in medical records; protection of patient data and information; and compatibility of electronic systems with standardized variables and metadata set by the Ministry of Health.

Sanctions for Non-Compliance

Administrative sanctions under Pasal 41 of PMK 24/2022 are applied in stages: written warning is the first official notice from health authorities. Sanctions range from written warnings up to revocation of accreditation status for facilities that fail to adopt electronic medical records and integrate with SATUSEHAT.

06Medical Records as Legal Evidence

Medical records serve not only a clinical function but also a legal one. The exam may present vignettes involving malpractice or forensic situations where the status of medical records as evidence is tested.

Functions of Medical Records

Medical records can serve as written evidence in criminal cases, and under article 164 HIR, they can be used as written evidence in civil cases.

For medical records to be admissible as legal evidence, they must meet the following criteria:

• Not written in pencil

• No erasures or correction fluid (tip-ex)

• Errors should be corrected by crossing out with a single line, initialed, and dated

• Complete and legible

The content of medical records constitutes medical confidentiality that must be guarded. Unlawful disclosure of medical record content can subject the responsible healthcare professional to criminal, civil, and/or administrative sanctions.

07Legal Consequences of Violations

Opening medical record confidentiality can subject healthcare workers to criminal, civil, and administrative sanctions. Criminally, a penalty of up to 9 months imprisonment may be imposed under Pasal 322 KUHP.

08Differential Concepts and Distractors

09Traps and High-Yield Pearls

The most common way students lose points on medical record questions is by confusing ownership of the document with ownership of the content. The exam will present a vignette where a patient demands their "medical record file" or where a hospital administrator refuses to release information. You need to distinguish between the physical document (facility's property) and the informational content (patient's right).

Another frequent trap involves retention periods. When the vignette describes a hospital with electronic records, the answer is 25 years, not 5 years. Do not default to "5 years" if the scenario mentions digital or electronic systems.

A third trap is the confidentiality after death rule. If a vignette describes a deceased patient's family requesting the medical record, the confidentiality obligation persists. Disclosure to the family requires proper authorization and follows the same rules as for a living patient.

On disclosure questions, remember the hierarchy: patient consent is the default pathway. Court orders bypass the Ministerial approval requirement. Research and education always require de-identification of patient identity. A vignette that describes a researcher wanting medical records with patient names is always wrong.

Finally, watch for the sanctions escalation. The exam tests whether you know that penalties for breaching medical record confidentiality can be simultaneously criminal (Pasal 322 KUHP), civil (Pasal 1365 KUHPerdata), and administrative (Permenkes 24/2022). These are not mutually exclusive; a single violation can trigger all three pathways.

The core competency being tested here is your understanding that medical records are both a clinical tool and a legal instrument, governed by a layered regulatory framework that balances patient rights to information access with an equally strong obligation to protect confidentiality.