Evaluation Of The Completeness Of Administrative Requirements In The Release Of Medical Information To Guarantee Legal Standing

Abstract

Quality healthcare services rely heavily on the orderly administration of medical records to ensure patient data security. The release of medical information to third parties is an exception to medical confidentiality that must be executed selectively in accordance with Standard Operating Procedures (SOP) to prevent legal anomalies. A preliminary study at BLUD RSUD Buton Regency showed that 25% of information release files did not comply with the SOP, primarily due to incomplete power of attorney documents. To evaluate the completeness of administrative requirements in the release of medical information through a systems approach (input, process, output) to ensure legal validity at BLUD RSUD Buton Regency. This study utilized a qualitative research design with a descriptive approach. Data collection was conducted through in-depth interviews, direct observation using checklists, and documentary studies of medical information release files. The input component indicated that human resources, SOP documents, and policies were available; however, physical documents on desks and staff legal understanding required improvement. In the process component, inconsistencies were found in the staff's bureaucratic workflow and the validation of power of attorney authenticity. The output component had not achieved the 100% target due to the remaining presence of documents lacking a valid power of attorney. The medical information release procedures have not operated optimally due to administrative loopholes in the applicant's power of attorney requirements. It is recommended to conduct regular audits, provide standard power of attorney forms, and socialize personal data protection in compliance with Minister of Health Regulation (Permenkes) No. 24 of 2022.