E-ISSN 2549-0680 Vol. 6, No. 2, July 2022, pp. 184-203 doi: https://doi.org/10.24843/UJLC.2022.v06.i02.p04 This is an Open Access article, distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/) 184 Ownership of Medical Records in Indonesia: Discourse on Legal Certainty and Justice Ambar Dwi Erawati * Medical Informatics Study Program, Widya Husada Semarang University, Semarang, Indonesia Hargianti Dini Iswandari ** Medical Informatics Study Program, Widya Husada Semarang University, Semarang, Indonesia Abstract Medical disputes between patients and health workers place medical records as a vital document for evidentiary in a court proceeding. The existing law and regulations in Indonesia determine that the medical record file is owned by the health service facility, while the patient receives a summary of the medical record. This study aims to analyze medical record ownership in Indonesia from perspectives of legal certainty and justice. This article reflects normative juridical research that explores relevant primary and secondary legal materials to be analyzed deductively. This article concluded that the obligation of health workers to make medical records in proving that they have delivered properly a health service as stipulated in the law and regulations reflects a legal certainty. However, laws and regulations governing the ownership of medical records seem not to fully reflect the principle of justice since medical record files are owned by doctors, dentists, or health service facilities. Even though patients/health service recipients are entitled to requesting the files from health care facilities, the sense of justice for the patients would be in the form of easy procedures for obtaining medical records. Keywords: Certainty; Health Law; Indonesia; Justice; Medical Records. 1. INTRODUCTION The number of medical malpractice cases in Indonesia in recent years has gradually raised the awareness of society regarding the importance of medical records. To prevent such malpractice cases, some people ask health workers and health service facilities to deliver their medical records. These medical records are usually kept for their document, while some others transmit the information contained in the records to their relatives and friends for a “second opinion.” 1 Determining whether a medical action meets the element of malpractice is not an easy task. The allegation of medical malpractice must be examined by collecting facts and evidence to be further assessed for its compliance with standard operating procedures, health workers‟ code of ethics, and * Email/Corresponding Author: ambar.dwi@uwhs.ac.id and ambarerawati@gmail.com ** Email : dini_iswandari@uwhs.ac.id and hargianti.dini@gmail.com 1 Term „second opinion‟ is commonly used in Indonesia, refers to a non-binding opinion delivered by health workers who are asked for opinion and advice. See also Decision of the Supreme Court No. 21P/HUM/2011 (Judicial Review on Regulation of Minister of Health No. 269 /Menkes/III/2008 concerning Medical Records), 13.