Implementation of Medical Records in Physiotherapy Services Home Care in Semarang City

Many physiotherapists in the city of Semarang provide online health services and home care, By Minister of Health Regulation No. 269 and Law No. 36 of 2014 Article 56 (d), health workers are required to keep medical records. Medical records contain records of patient treatment, both written and recorded, which contain the patient's identity, history, laboratory, and diagnosis. This research aims to determine the implementation of medical records in physiotherapy services and home care in the city of Semarang, with analytical descriptive sociological juridical methods. In terms of how data collection is carried out by observation, interviews, questionnaires, documentation, and a combination of the four. The data results are analyzed systematically according to the factual and actual situation of the incident based on facts, characteristics, and phenomena by looking for cause and effect. The research results show the implementation of medical records in physiotherapy services and home care in the city of Semarang is not going well, because it is still found that 37.1% of physiotherapists have not carried out medical records. The physiotherapist can be given sanctions for violating UUPK number 29 of 2004 with a maximum penalty of 1 year and a fine of up to 50 million.


INTRODUCTION
The basic human need is health, with a healthy mind and body being the initial key to starting activities in human life.Health services can be achieved without the support of quality health infrastructure (Chusniah Windi, 2019).Health services will be well documented according to operational standards if medical records are recorded based on written evidence from the health service process and administration to create sustainable services.
Physiotherapy is one of the health workers who have the following role meaning: a form of health service aimed at individuals and/or groups to develop, maintain, and restore body movement and function throughout the life span by using manual treatment, increased movement, equipment (physical, electrotherapeutic and mechanical) functional training, and communication (Kementerian Kesehatan Republik Indonesia, 2015).
Al Manhaj: Jurnal Hukum dan Pranata sosial Islam 52 Physiotherapy is a health worker who provides health services by recovering impairment and maintaining functional limitations and disabilities optimally.Starting from the beginning of life, namely childhood to old age.Physiotherapy in Indonesia works in two fields, namely as a health worker at a health agency and as an independent physiotherapist.However, a physiotherapist can also carry out his work in both fields at the same time by working in a health agency and providing health services independently home care, or accepting patients at independent practices.Independent physiotherapy can accept patients with and without a referral from a doctor as stated in the Minister of Health Regulation Number 80 of 2013 concerning the Implementation of Physiotherapist Work and Practice in section 16 paragraph (2) which reads: "in providing services as referred to in paragraph (1) Physiotherapy can accept patients directly or based on referrals from other health workers (Kuswadani et al., 2018).
With the increasingly rapid development of the times, physiotherapy health services can also be enjoyed freely in-home care to pamper patients without the hassle of coming to a health agency, thereby making things easier for the community.Physiotherapy health services home care It has become a prestigious thing to call physiotherapy to your home privately to reach the maximum peak in the recovery process for the disease the patient is complaining about.
Physiotherapists in providing health services must consider legality in every action so that both parties, both physiotherapists and patients, feel legally protected because according to Heriani, malpractice from health services intentionally or unintentionally can harm patients as service consumers by Law Number 8 of 1999 concerning Consumer Protection (Heriani, 2018).This is done to prevent patient dissatisfaction which results in legal demands for physiotherapy as health workers, such as the incident in 2017 where there was a lawsuit from a patient at the Royal Taruma Hospital, Grogol, West Jakarta because the patient felt he was a victim of malpractice from physiotherapy services which resulted in a burn occurred on his right shoulder.An incident like this could have occurred as a result of physiotherapy health services home care.
Efforts to protect consumers in Indonesia aim to uphold the principle that consumers as consumers, users, or beneficiaries of goods and services need to be given legal protection.Apart from that, consumers are also the parties who determine the continuity and growth of service businesses, so consumer protection is very important for the success of these service businesses (Hidayat & Ginting, 2023).
Health workers including physiotherapists who provide health services on an ongoing basis home care medical records are also required by Minister of Health Regulation no. 269 and Law no. 36 of 2014 article 56 (d), this is an effort to provide legal protection for physiotherapists and patients.A medical record is a track record of a patient's treatment, both written and digitally recorded, which contains the patient's identity, history, diagnosis, laboratory, and all health services the patient has received.In other words, medical records are a collection of a person's health facts from the type of disease, and current and past treatment history written by health practitioners in their efforts to provide the best health services to patients (Andi Ritonga & Maya Sari, 2019).
Talking about medical records, we will inevitably see 2 (two) important parts that need to be considered, namely: patient records and management.Patient record is information recorded in both written and electronic form about the health condition and illness of the patient concerned.Patient record In general, it is individual, there are never health records from several people collectively in a medical record.The second part is related to Management.Management is a process of processing or compiling a patient's health condition and illness so that it can become useful information for carrying out accountability in terms of management, finances, and the condition of the patient's health development (Handiwidjojo, 2019).
The quality of medical records is a reflection of the good and bad of a health service.Currently, some health workers still do not realize the importance of medical records.Medical records can be used as evidence in cases that violate the law, for example, malpractice, which must be submitted to court.The contents of medical records must be kept confidential by doctors, dentists, health workers, management officers, and leaders of health service facilities (Alfiansyah et al., 2020).The system for creating medical records must comply with existing legalities in Indonesia, both manual medical records and electronic medical records.To support the creation of the above documentary evidence, Physiotherapy must know how to create medical records both manually and electronically according to legality and create an integrated form design (S. S. Kuswardani, 2021).
Sometimes mistakes are made in the implementation of medical services which result in the patient suffering losses or what is called medical malpractice.The existence of medical records is required in health service facilities, both from the perspective of implementing health service practices and from the legal aspect.Legal regulations relating to the implementation of health services include aspects of criminal law, civil law, and administrative law.From a legal aspect, medical records can be used as evidence in legal cases (Abduh, 2021).
The phenomenon of low awareness of health workers in making medical records also still occurs among independent physiotherapy health workers in the Semarang city area.According to previous research conducted by researchers in 2018, it was found that out of a total of 9 independent physiotherapy practice places in the city of Semarang, 4 practice places were still found.an independent physiotherapist who does not carry out medical records.These findings made researchers interested in creating community service regarding the implementation of medical record management by legality in online independent physiotherapy in the city of Semarang in 2021, which was attended by 30 independent physiotherapists.This research seeks to find an overview of the implementation of medical records in independent physiotherapy services that provide health services and home care in the city of Semarang.Because medical records are mandatory, and if we violate them, Minister of Health Regulation number 269 of 2008 concerning medical records in chapter 17 paragraph (2) states that we will receive administrative sanctions as referred to in paragraph (1) which can be in the form of verbal warnings, written warnings up to license revocation.

METHOD
The method used in this research is the sociological juridical method, which is research on legal identification and legal effectiveness in social dynamics (K.Kuswardani & Abidin, 2023).The sociological juridical method approach interprets law as a reality that can be influenced by other Law is often related to dynamics in society that will and are currently occurring.Sociological legal research is not legal research, but research that has the same object, namely law (Said, 2021).
Sociological juridical research is a study that studies causal variables that arise from various forces in social processes and produces conclusions according to social science pattern designs (Wardhani, 2014).The specifications for this research use analytical descriptive specifications, descriptive in this research means that the research results will provide a comprehensive, systematic, and in-depth picture of a condition or symptom being studied (Zuchri, 2021), regarding the implementation of medical records in physiotherapy services home care in the city of Semarang.
In qualitative research on the implementation of medical records in physiotherapy services and home care in the city of Semarang, the emphasis is on quality, not quantity, There are 3 types of data used by researchers here, namely: a.The primary is collecting data directly from respondents through questionnaires, interviews, and direct observation of independent physiotherapists who provide health services and home care.
Respondents are members of the Semarang branch of the Indonesian Physiotherapy Association.
b. Secondary can be seen from the existing laws and regulations in our country, Indonesia.c. Tertiary is obtained from literature studies and field studies.
The research subject is to define the research subject as an object, thing, or person to which the data for the research variable is attached, and which is at issue (Harlan & Sutjiati, 2018).The subjects in this research are physiotherapists who provide health services and home care in the Semarang city area who were willing without coercion to become one of the participants with a guarantee of identity confidentiality, namely 35 people.Of these 35 people, 10 people underwent direct observation, interviews, and questionnaires, and 15 people answered questions via questionnaires without answer limits.
Data collection seen in terms of methods or collection techniques can be done using observation, interviews, questionnaires, documentation, and a combination of the four (Iryana, 2022).Researchers conducted observations, interviews and created an open questionnaire of 26 questions with a focus on the process of implementing medical records in physiotherapy services.home care in the city of Semarang.This research will take place from September -December 2023, after the data has been collected and analyzed systematically according to situations or events in a systematic, factual, and actual manner according to the facts, nature, and relationships by the phenomenon by looking for cause and effect (Kuswadani et al., 2018), in the sense that the process of this researcher carries out an analysis of existing problems so that conclusions are drawn using descriptive analysis to get an overview and analyze systematically regarding the implementation of medical records in physiotherapy services home care in the city of Semarang.

Implementation of Home Care Physiotherapy Health Services in Semarang City
Health workers are people who have educational knowledge and skills and dedicate themselves specifically to their field in the field of health services.Physiotherapists here are also health workers  (Kuswardani, 2022).
In Indonesia itself, there are still many medical personnel and health workers who do not have a Registration Certificate (STR) but are still practicing as health workers.Physiotherapy includes workers who work in the health services sector who sometimes make mistakes and if they are proven to have made mistakes in their practice or services, they must be given legal and continental sanctions.
The Indonesian Ministry of Health explained that there is data at the Provincial Health Service Office that there are 636 physiotherapy workers who do not have STR, 3,223 Registration Certificates (STR) have not been issued and 12% of STR are no longer valid.It can also be shown by case evidence from the Supreme Court's court decision with the results of Decision Number 50 p/HUM/2020 in Jakarta that a physiotherapist had carried out health procedures without STR (Atmaja & Putra, 2022).
A physiotherapist is any person who has passed physiotherapy education by the provisions of statutory regulations, and based on their education, physiotherapists are qualified as follows (Kemenkes, 2013) Physiotherapy health services in Indonesia are not only available at referral-level healthcare care facilities but can be found in several basic/primary-level healthcare facilities (Puskesmas Basic Data 2013) including general physiotherapy health services.home care which increasingly pampers consumers of their services.With the development of ways to obtain health services, regulations, and adjustments are needed so that the accessibility and quality of physiotherapy services can be accounted for (Kementerian Kesehatan Republik Indonesia, 2015).It is legal for a physiotherapist to provide health services home care as long as it is by existing legal regulations, by Minister of Health Regulation number 9 of 2004 concerning Clinics that provide promotive, preventive, curative, and rehabilitative health services as intended in paragraph (1) carried out in the form of outpatient, inpatient, one day services (one daycare) and/or home care (Kemenkes, 2014).

Implementation of Medical Records in Home Care Physiotherapy Health Services in Semarang
City.
A medical record is a document or note containing facts relating to the patient's personal data and condition, disease history, and past treatment made by certain health workers who provide health services to the patient.The function of medical records is to provide information on the patient's condition to health workers involved in providing health services to the patient concerned.Indicators of quality health services can be seen from the contents of complete medical records, as well as the speed and accuracy in creating medical records (Rika et al., 2020).
The contents of medical records at a health service facility are an indicator of the quality of health services.Based on the data contained in the medical record, it will be possible to assess whether the health services provided are good enough or not, and can also be assessed to be by professional operational standards or not.To achieve good quality, the Ministry of Health needs to regulate the procedures for administering medical records in a Minister of Health regulation so that the signs are clear (Nuraini, 2015).
A good medical record that is considered complete in its contents must be made by health workers c.Legal aspect, the contents of medical records can be used as evidence of the health service process that has been received and as evidence in upholding justice.
d. Financial aspects, based on the contents of medical records, can be used to determine the cost of treatment or procedures received by the patient.
e. Research aspect, the contents of medical records can be used as research material in the health sector.
f. Educational aspect, the contents of medical records can provide information about medical services for a disease and can be used as learning material.
g. Documentation aspect, the contents of the medical record are the results of documentation of the health services the patient received during treatment.
The benefits of medical records, in general, can be used as a history of the patient's illness during subsequent treatment, enforcing the ethics of health workers, for educational purposes, research, legal process evidence, financing, and health statistical data.The use of medical records for educational and research purposes is not permitted to write down the patient's identity, because confidentiality must be maintained.and also being responsible for medical records.These medical record regulations apply to all health service facilities and also health workers who are directly involved in providing health services to patients (Rahayu et al., 2017), including health services provided by physiotherapists in-home care.
In Permankes 269 of 2008 concerning medical records, every doctor, dentist, and certain health workers who carry out direct action on patients are required to comply with this provision.Although the results of this research still found physiotherapists providing physiotherapy health services and home care in the city of Semarang they do not make medical records.
Medical records can be made conventionally by writing or by digital or electronic medical records according to current developments.From the results of interviews and questionnaire data recaps, researchers found that 28.6% of them had done electronic medical records, 34.3% had done manual written medical records, and 37.1% of the total respondents had not done medical records at all.c.Medical records must be completed immediately after completing medical procedures.
Medical records are created not only to be authentic documents in court, but medical records can be used as evidence in court regarding the process of health services provided by health workers to patients, although they still require further interpretation.It would be better for home care physiotherapy to continue to document all health services that have been provided to patients in medical records, because if there is a default, the medical record can be used as evidence, although it is still debatable if the health services provided do not comply with the established physiotherapy a.An authentic deed is a deed made with certain rules and made by and or in front of an official in authority.

Fisioterapi Home Care
b.A private deed is a deed made without the knowledge of a public official and deliberately used as evidence.
c. Ordinary letters, namely letters not made to be used as evidence.
The implementation does not mean that medical records are inseparable from legal aspects, because medical records are an inseparable part of health law, the legal sanctions related to the implementation of medical records are: b) Recommendations for revocation of registration marks or practice permits.
2) Minister of Health Regulation number 269 of 2008: given guidance, supervision by the minister, the head of the provincial health service, the head of the district/city health service can take action according to their respective authorities, such as verbal, written warnings, up to the revocation of practice permits.

CONCLUSION
Based on the results of research on the implementation of medical records in home care physiotherapy services in the city of Semarang, it can be concluded that there are still physiotherapists who commit legal violations in providing home care health services in the Seamarang city area, just as there are still physiotherapists with three/four diploma graduate backgrounds without supervision, from professional physiotherapists or health agencies, and other violations are still found in physiotherapists who do not carry out medical records either conventionally or electronically on purpose.The Semarang city branch of the Indonesian Physiotherapy Association needs to hold training on how to create medical records both conventionally and electronically in providing health services in independent practice or home care.
Based on the results of research on the implementation of medical records in-home care physiotherapy services in the city of Semarang, it can be concluded that there are still physiotherapists who commit legal violations in providing home care health services in the Semarang city area, just as there are still physiotherapists with three/four diploma graduate backgrounds without supervision, from professional physiotherapists or health agencies, and other violations are still found in physiotherapists who do not carry out medical records either conventionally or electronically on purpose.The Semarang city branch of the Indonesian Physiotherapy Association needs to hold training on how to create medical records both conventionally and electronically in providing health services in independent practice or home care.
factors.Sociological juridical research has several study characteristics, including (Huda, 2021): a. Implementation of laws in society that are not recorded in law.b.It is a posteriori, namely knowledge that relies on empirical evidence.c.Its validity is based on legal reality facts.d.The emphasis of the data is based on the meaning of the researcher's ideas, which are related to law.
who can provide health services to patients independently or in health institutions.Physiotherapy who can provide health services independently or not should have a Registration Certificate (STR), Physiotherapy Practice Permit (SIPF), or Physiotherapy Work Permit (SIKF) by Minister of Health Regulation No. 80 of 2013 concerning the Implementation of Work and Practice for Physiotherapists Independent physiotherapists are physiotherapists who set up independent practice places and physiotherapists who provide health services independently home care to patients independently outside the supervision of certain health agencies.Physiotherapy in the Semarang city area provides comprehensive health services and home care The number is not yet known, because physiotherapy health services are in-home care It can also be done by independent physiotherapy graduates of professional physiotherapy or physiotherapy graduates with three/four diplomas who work in health institutions provided they are under the supervision of the health institution.By Minister of Health Regulation number 80 of 2013 in article 6 paragraphs 1 -4 which reads (Kemenkes,2013): a. Physiotherapists can practice Physiotherapy services independently or work in Health Service Facilities.b.Physiotherapists who practice Physiotherapy services independently as intended in paragraph (1) must be Professional Physiotherapists or Specialist Physiotherapists.c. Intermediate Expert Physiotherapists or Applied Science Physiotherapists can only work in Health Service Facilities.d.An Intermediate Expert Physiotherapist or Applied Science Physiotherapist as referred to in Kuswardani / Implementation of Medical Records in Physiotherapy Services Home Care in Semarang City 57 paragraph (3) must work under the supervision of a Professional Physiotherapist or Specialist Physiotherapist.As a result of observations in the field, researchers still found several physiotherapists whobackground third/fourth diploma education and in providing health services home care without supervision by professional physiotherapists or authorized health agencies.The results of this research obtained the level of education of physiotherapists who provide health serviceshome care in the Semarang city area, there were 45.7% of Diploma three graduates, 22.9% of Diploma four graduates, and 31.4% of professional graduates from a total of 35 respondents.

Figure 3 . 1
Figure 3.1 Graphic of physiotherapy education providing serviceshome care who provide health services to the patient concerned within the time and resume by the regulations of the Minister of Health of the Republic of Indonesia No. 269/Menkes/PER/III/2008, which states the minimum requirements that must be met.completed by health workers.The contents of the medical record should contain patient identity, date and time, history, disease history, laboratory results, medical diagnosis, health service management plan, treatment history, informed consent, observation notes, names, and signatures of certain health workers who provide health services.According to Hatta in 1985, medical records have several purposes, including (Abduh, 2021): a. Administrative aspect, the contents of medical records have administrative value because they contain medical actions from medical staff to achieve the best quality of health services.b.Medical aspect, because it contains records from patient identification, treatment plans, and actions, to evaluation.
The administration of medical records is regulated in the 1945 Constitution, Law Number 29 of 2004, Law Number 36 of 2009, Law Number 44 of 2009, and Minister of Health Regulation Number 269 of 2008.These regulations contain procedures for storing documents, maintaining medical records,

Figure 3 . 2
Figure 3.2 Graphic of medical record recap for home care physiotherapy in the city of Semarang number 29 of 2004: deliberately not making medical records can be punished with a fine of 50 million rupiah 2) KUUHP: a) Article 267 paragraph (1) states that: whoever deliberately provides a false certificate regarding the presence or absence of disease, weakness or disability, is threatened with imprisonment for a maximum of four years.This happens if a health worker changes or deletes the contents of a medical record without complying with the rules.b) Article 322 paragraph (1) states that: anyone who deliberately discloses a secret that he or she is obliged to keep because of his/her position or employment, whether current or previous, is threatened with imprisonment for a maximum of nine months.With an example, a health worker discusses the condition and behavior of the patient he is treating in front of many people.b. Civil Civil sanctions for certain health workers who intentionally fail to record medical records can be prosecuted under Article 1234 of the Civil Code and Article 1239 of the Civil Code.c.Administration 1) UUPK number 29 of 2004: a) Providing written warnings.
So medical records are very useful for health workers and of little use to patients.The position of medical records in criminal procedural law is as evidence in the form of letters, in accordance with the provisions of Article 187 of the Criminal Procedure Code and Article 13 paragraph (1) letter e of Minister of Health Regulation No. 269/MENKES/PER/III/2008.The definition of a letter in this case is as written evidence made based on the health worker's oath of office.In article 187 of the Criminal Procedure Code, there are 3 types of letters, including (Abduh, 2021):