Information on medical records of covid-19 patients in Indonesia

Background of the study: This research describes medical record management activities in two government hospitals in Indonesia, namely RSUD Tugurejo Semarang and RSUD Kota South Tangerang. This Hospital became history for the Indonesian people during the COVID-19 era and became a referral hospital for COVID-19 patients. Medical records, as written documents regarding the initial history of a patient's illness, can be trusted in the name of law and become archives with legal and historical value. Therefore, it is necessary to look at how the medical records of COVID-19 patients are recorded and utilized.

Purpose: Analyze the use of COVID-19 medical records as a source of health information data in hospitals.

Method: This research uses descriptive qualitative methods. Data sources come from observation, interviews, and documentation.

Findings: The research results found that medical records at General Hospitals in Indonesia are managed based on life cycle files, following the guidelines issued by the Regulation of the Minister of Health of the Republic of Indonesia Number 24 of 2022 concerning Medical Records.

Conclusion: The more organized a hospital's medical record archive is, the more information contained in the medical record will be visible to researchers.

Introduction

According to WHO, Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus (Coronavirus disease (COVID-19) (World Health Organization., 2023). This disease is in the same family as SARS and MERS, which causes many people to die(Liu et al., 2020). The government has made various efforts to save its citizens by enforcing various policies. One of them is Indonesia, which is implementing Large-Scale Social Restrictions (PSBB) in the hope that the spread of COVID-19 will become more widespread.(Tinambunan et al., 2021). Then, in 2022, various countries began to be able to overcome the spread of COVID-19, and Indonesia has begun to provide leeway in wearing masks in open spaces, except for the elderly or people who are sick(Humas, 2022).

Historically, the COVID-19 outbreak, or pandemic, is not the first to hit many parts of the world. According to(Beach et al., 2020), the current COVID-19 pandemic is similar to the influenza pandemic that occurred in 1918. Both pandemics resulted in respiratory illnesses that spread highly infectious viruses. This virus spread massively throughout the world in just a few months. Therefore, researchers began to open old health archives, including medical records, to discover past medical records. According to data from January 3, 2020, to August 30, 2023, from WHO sources regarding handling COVID-19, there are around 6,813,095 confirmed cases of COVID-19, with 161,916 deaths reported to WHO (World Health Organization., 2023).

After the disaster spread, the Indonesian government realized the importance of studying archives during the pandemic. Therefore, the government issued the rescue of COVID-19 archives through a circular issued by the Ministry of State Apparatus Empowerment and Bureaucratic Reform of the Republic of Indonesia number 62. After the disaster spread, the Indonesian government realized the importance of studying archives during the pandemic. Therefore, the government issued the rescue of COVID-19 archives through a circular issued by the Ministry of State Apparatus Empowerment and Bureaucratic Reform of the Republic of Indonesia number 62. After the disaster spread, the Indonesian government realized the importance of studying archives during the pandemic. Therefore, the government issued the rescue of COVID-19 archives through a circular issued by the Ministry of State Apparatus Empowerment and Bureaucratic Reform of the Republic of Indonesia number 62 of 2020 concerning Saving Archives in Handling COVID-19 to Support Accountability for the Performance of Government Agencies. The letter states that performance, allocation of energy resources, and the impacts that arise need to be recorded and stored correctly as a form of accountability and a valuable learning source for every generation of Indonesia, even the world community. The scope of this letter includes COVID- 19 rescue files handled by archive creators and the preservation of static archives at archival institutions(Indonesia, 2020).

March 2, 2020, was the first day Indonesia started documenting everything related to Covid-19. At that time, the two residents had direct contact with Japanese citizens who were visiting Indonesia(Sukur et al., 2020). Records of patients in the Hospital are listed in the medical record. In principle, the contents of medical records must be protected, but in the case of COVID-19, it is necessary to revise the access rules contained in medical records. So, to respond to this, the government made special regulations regarding medical records for COVID-19 patients whose information can be disclosed for future research purposes(Noor et al., 2022). The rules for open access to medical records of COVID-19 patients are regulated in the Decree of the Honorary Council for Medical Ethics Number: 016/PB/K.MKEK/04/220 concerning Revision of the Fatwa on Medical Ethics, Health Policy and Research in the Context of the COVID-19 Pandemic(Indonesia, 2020).

The quality and accuracy of hospital data are crucial to report. This can be seen from the results of research conducted by(Sudat et al., 2021), stating that hospitals in California, when the COVID-19 pandemic hit, were required to provide daily reports. The information reported relates to the number of emergency units, inpatient admissions, public hospital occupancy, ventilator use, hospital capacity, surgical bed use, the amount of protective equipment used, the number of hospital staff, and the number of deaths in the Hospital.(Dron et al., 2022)emphasized that the importance of data collected by hospitals routinely is vital for research both before and during the COVID-19 pandemic. Research that uses this data can be called real-world evidence. Applying this concept, the US Food and Drug Administration stated that real-world evidence data could only be collected through Health Electronic Records (HER), which can be collected, followed up on, and meaningful. The research conducted by Asghari stated that when COVID-19 hit, the Hospital also stored nursing interventions for each COVID-19 patient as a patient health archive. This nursing intervention record is used by Sina Educational Hospital, one of the referral hospitals for COVID-19 patients in Tabriz, Iran, as a supporting file provided by nursing to help analyze the patient's illness(Asghari et al., 2022).

Another research discusses the management of prevention and control of COVID-19 in the Medical Records Work Unit conducted by(Andriani, 2021). This research aims to discover how to prevent and control COVID-19, especially in the Medical Records Work Unit. The research results show that the Indonesian Association of Professional Medical Recorders and Health Information (PORMIKI) has issued a circular containing precautionary and protective measures for Medical Recorders and Health Information (PMIK)