Friday, September 09, 2022, the PKRS unit held counseling on Medical Certificate Making Service Procedures in the Polyclinic waiting room with resource persons: Yuli Pujiastuti, A.Md.Kes.

Creation of Medical Certificate

Medical records are files that contain records and documents about patient identity, examination, treatment, actions and other services that have been provided to patients. Based on the Minister of Health Regulation No. 269 / MENKES / PER / III / 2008 concerning medical records, article 10 paragraph (1) that information about the identity, diagnosis, medical history, examination history and treatment history of patients must be kept confidential by doctors, dentists, certain health workers, management officers and leaders of health service facilities. The head of the health facility is responsible for the loss, damage, forgery and or use by unauthorized persons or entities of medical records. Maintenance of information must be done properly in accordance with ethics, standards and the law. If the release of medical information is not in accordance with applicable laws and regulations, it may be subject to sanctions such as license revocation, fines, and even imprisonment. A patient's medical information can be provided to related parties, among others:

1. Patient

2. Patient's family (parents, husband/wife, children)

3. Insurance

4. Referral hospital

5. Other doctors treating the patient

6. Police or other law enforcement and TNI

7. Court needs

A medical certificate is a letter that summarizes a patient's medical information, including diagnosis, history of illness, and therapy. A medical certificate is made by the doctor treating the patient. A medical certificate is a form of release of medical information, so it must be done in accordance with the rules. There are two forms of release of medical information based on the request and designation, namely:

1. Certificate for "Pro Justitia" purposes: including Visum et Repertum

2. Certificate for "Non Pro Justitia" purposes: medical certificate for insurance, birth certificate, death certificate, hospitalization certificate, health certificate.

Conditions for making SKM:

1. Social data of the applicant;
2. Copy of Identity Card (KTP), if the applicant is the patient himself (minimum age 18 years);
3. Copy of Birth Certificate/Child Identity Card (KIA), if the applicant is a parent (child is less than 18 years old);
4. Social data of the patient, the patient's medical record number and the period of visit for which the Medical Certificate is requested;
5. Fill out the Form of authorization to the health care facility to open the patient's medical record in connection with the process of making a medical certificate and the purpose of requesting a medical certificate;
6. Date the request was made;
7. Applicant's signature;
8. If necessary, it should be accompanied by a stamp duty.

Attachment of application for medical certificate:

1. Direct request from the patient

Photocopy of supporting data: Copy of Identity Card (KTP), if the applicant is the patient himself/herself (at least 18 years old); Child Identity Card (KIA), if the applicant is a parent (the child is less than 18 years old);

2. Request not from the patient

Power of attorney stamped Rp.10,000 and other supporting data, except from law enforcement.

The contents of the medical certificate include:

1. Letterhead;
2. Patient identity;
3. Date of treatment and treatment room;
4. Inspection;
5. Diagnosis;
6. Action;
7. Date of the medical certificate;
8. Signature of the Responsible Doctor;

Medical certificate collection requirements:

1. The patient picks up the medical certificate in person;
2. If the applicant is not a patient, there must be a power of attorney from the patient;
3. If the applicant is a third party, there must be a power of attorney from the patient or family;
4. The applicant must complete payment of the administrative fee for the production of the medical certificate.

The release of medical information must follow the applicable procedures, namely with written consent and permission from the patient. Without the patient's consent/request, the hospital or doctor is not allowed to provide the patient's medical data except for referral purposes or at the request of law enforcement or the court.