Patient Rights to Medical Records
The law stipulates that not providing medical records, which are the patient's right, as specified in the Minister of Health Regulation ( Permenkes ), is an unlawful act that can have serious consequences for medical personnel and health facilities.
The tragic case experienced by Agus Ramlan is a critical case study that underscores the urgency of fulfilling this fundamental right.
The dark story of Agus Ramlan (hereinafter referred to as the "Plaintiff") began when he had his left eye examined by Dr. Maryono Sumarno, Sp.M (hereinafter referred to as the "Defendant I") at Rajawali Hospital in Bandung (hereinafter referred to as the "Defendant II"). On his first visit, Agus was given eye drops and tablets without adequate explanation regarding his eye condition or how the medication worked, and unfortunately, his condition showed no improvement. His condition worsened on his second visit, where the eye ointment worsened his vision.
After replacing the eye drops, tragedy struck. Agus experienced total blindness. He was then hospitalized at Rajawali Hospital, but without significant improvement. His family's earnest request to refer Agus to another doctor, who could provide better treatment, was flatly rejected. Even more shockingly, Agus continued to undergo outpatient treatment for over 10 years, following Dr. Maryono's practice at various locations, including Al Islam Hospital and his private practice. A shocking fact emerged during this incredibly long period: Agus never had access to his medical records. Ironically, these crucial medical records were later discovered to have been unilaterally destroyed by the hospital and doctor, eliminating a critical trace of his treatment journey.
Feeling that his rights as a patient had been fatally violated, and with the loss of his medical records, which served as crucial evidence, Agus Ramlan finally dared to file a lawsuit for Unlawful Acts (PMH). This lawsuit was based on two main pillars: violating the patient's right to obtain information and access his medical records, and the illegal act of destroying medical records. In his lawsuit, Agus sought material damages of Rp1.05 billion, covering various direct losses he suffered and immaterial damages of Rp1 trillion as compensation for extraordinary physical and mental suffering, plus demands for accountability from the relevant professional organizations. The Bandung District Court, after reviewing the evidence and arguments, ruled that the Defendants had indeed committed an unlawful act, sentencing them jointly and severally to pay material damages of Rp250 million and immaterial damages of Rp500 million. However, this decision, which had brought some hope for Agus, was dashed when the Bandung High Court overturned it.
Undeterred, Agus Ramlan took his case to the highest judicial level in Indonesia. The Supreme Court (MA) provided significant legal enlightenment at the cassation level. The MA carefully considered that the Defendants' actions of never providing the contents or photocopies of medical records, despite repeated requests from the patient or his family, clearly demonstrated a violation of their fundamental legal obligations. The legal basis was clear: Article 10 paragraph (2) of Minister of Health Regulation No. 749a/ MenKes /Per/XII/1989 explicitly states that medical records belong to the patient. This means that the patient has full rights to the information contained therein. Furthermore, Article 14 letter b of the same Minister of Health Regulation also emphasizes that medical records can be used as evidence in legal cases. The implications of this article are crucial, namely that the Defendants are obliged to provide these medical records and the Plaintiff has full rights to receive them. This vital legal relationship is further reaffirmed in Article 47 paragraph (1) and Article 52 letter e of Law Number 29 of 2004 concerning Medical Practice, which comprehensively regulates rights and obligations in medical practice. Based on these strong and comprehensive legal considerations, the Supreme Court finally ordered Dr. Maryono Sumarno (Defendant I) and Rajawali Bandung Hospital (Defendant II) to jointly and severally pay material compensation of Rp. 250 million and immaterial compensation of Rp. 500 million to Agus Ramlan.
*) Abdul Hamim Jauzie; Lawyer
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