Study on hospital responsibilities regarding the completeness of medical resumes

Objective: Hospitals are legally responsible for the excellent service quality provided to patients based on statutory provisions. Hospital responsibilities in health services include criminal, civil and administrative liability. This study aims to determine the responsibility of the hospital in documenting medical resumes.

Methods: The research method used is literature review, through review of research journals related to the completeness of medical resumes that have been published on accredited journal platforms in 2010-2020. This research was conducted in August-October 2020.

Results: Analysis of 20 research journals relating to the completeness of medical resumes in the reviewed hospitals, it is known that the completeness of medical resume documents in the hospital is on average 75.80% Only 2 hospitals out of 20 hospitals documented medical resumes in accordance with the minimum hospital service standards. Based on the prevailing laws and regulations, the hospital is not criminally responsible for the incomplete documentation of medical resume, but the hospital is responsible civilian based on the principle of representative responsibility and administratively.

Conclusion: The hospital has not optimally documented medical resumes in accordance with the minimum hospital service standards. As a result, the hospital is both civilly and administratively liable. Supervision of the doctor's performance in documenting medical resumes and the role of the medical record committee in ensuring medical staff complete all medical records of patients served is required.