Legal Certainty Regarding Electronic Medical Record Retention Period

Abstract

A medical record is a file containing notes and
documents about the patient’s identity, examinations,
medication, actions, and other services that have been
provided to patients. National hospital accreditation
standards (SNARS) edition 1.1 states that health care
facilities are required to provide the necessary facilities
in the context of administering medical records, starting
from the patient arriving to the patient returning home
and continuing with data processing, reporting, including
storage and maintenance (retention) of medical records.
The World Health Organization (WHO) states that
determining the retention period for medical records is
something that must be considered in order to meet the
needs of law, medical, management, education, research,
and so on, in accordance with applicable regulations in
the country concerned. Normative legal certainty is when
a rule is made and promulgated because it regulates
clearly and logically and not to cause doubts (multiple
interpretations). Legal certainty provides clarity in
carrying out legal actions. Legal certainty regarding the
retention period of electronic medical records is needed to
avoid legal problems considering that medical records are
documents that are regulated by law for the manufacture,
use and management. This research is normative juridical
and aims to identify legal certainty related to the retention
period of electronic medical records. From the results
of this study it can be concluded that there is legal
uncertainty regarding the retention period of electronic
medical records. Regulatory harmonization is needed to
create legal certainty regarding the retention period of
electronic medical records.