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Medical Records: Definition, Functions, and Integration with Digital Signatures

Written by VIDA | Sep 18, 2025 11:00:00 PM

 

 

One of the key efforts to improve the quality of healthcare services is through digitalization. This transformation enhances efficiency, accuracy, and security in medical operations.

A crucial part of this system is medical record management — a process that ensures patient data is recorded, verified, and stored properly.

Medical records are not just historical documents; they serve as the basis for medical decision-making and require proper validation and authorization from healthcare professionals.

For patients, this means faster, more transparent service. For healthcare providers (clinics, hospitals, and laboratories), it leads to higher efficiency and ensures compliance with legal regulations.

So, how does the implementation of digital signatures improve medical records? Let’s explore.

What Is a Medical Record?

A medical record is a document that contains a patient’s health information during treatment at a healthcare facility. This includes diagnosis, lab results, medical procedures, and prescribed treatments.

For patients, medical records function as a historical reference that can be accessed whenever needed. For healthcare providers, they form the foundation for accurate and continuous medical decision-making.

Common types of medical records include:

  • Inpatient Records: Document all medical actions taken while the patient is hospitalized.

  • Outpatient Records: Record consultations and treatments for patients who do not require admission.

  • Emergency Records: Capture procedures performed in emergency units.

  • Laboratory and Radiology Records: Contain diagnostic test results such as blood tests, urine analysis, CT scans, and X-rays.

  • Electronic Medical Records (EMR): Digital versions of all patient data integrated into an electronic system.

The digitalization of medical records allows data to be stored efficiently and accessed securely by authorized personnel.

Functions of Medical Records

Medical records are not just data collections — they are the core reference for efficient and continuous patient care. According to Indonesia’s Ministry of Health, the main functions include:

1. Comprehensive and Continuous Patient Care

Medical records give doctors access to a complete health history, making diagnosis and follow-up treatments easier and more accurate. Past consultations, test results, and prescriptions can all serve as valuable references for consistent care.

2. Faster Medical Services

Digitized medical records enable automatic verification of patient information. For example, hospitals can process pharmacy prescriptions faster since all necessary data is already stored electronically.

3. Transparency for Patients and Families

Medical records are not just assets for hospitals — they are also part of the patient’s right to information. Electronic Medical Record (EMR) systems offer transparent and controlled access, allowing patients to view their health history through secure portals or apps.

Digital Signatures for Medical Records

In Indonesia, the use of Electronic Signatures (TTE) or digital signatures for medical records is legally recognized and regulated through several official laws, including:

  • Ministry of Health Regulation No. 24 of 2022 on Medical Records (Article 3)
    States that electronic medical records can be equipped with digital signatures as a means of verifying and authenticating content and signer identity in accordance with prevailing laws.

  • Law No. 11 of 2008 on Electronic Information and Transactions (ITE Law)
    Confirms that electronically signed documents have full legal force if they meet the criteria of authenticity, integrity, and signer identity.

  • Government Regulation No. 71 of 2019 on Electronic Systems and Transactions
    Establishes the technical standards for implementing certified electronic signatures.

  • Law No. 27 of 2022 on Personal Data Protection (PDP Law)
    Regulates that medical records — classified as sensitive personal data — must be managed securely, with proper access control and user consent.

With this legal foundation, using digital signatures in medical records is not only legally valid but also strengthens security, transparency, and operational efficiency across the healthcare sector.

For patients, digital signatures ensure that their privacy is protected, since only authorized personnel can access and sign their records. Each signer’s identity can also be verified.

For healthcare providers, using encryption and certified electronic certificates from licensed Certificate Authorities (PSrE) such as VIDA ensures that medical records are protected from manipulation or forgery.

Approvals from doctors, patients, or administrative staff can be done in real time, without printing or manual signing.

VIDA Digital Signature Integration in Medical Record Systems

VIDA’s digital signature technology can be integrated directly into hospital management or EMR systems, allowing:

  • Doctors to digitally sign diagnoses and prescriptions.

  • Patients to provide digital consent for medical procedures.

  • Hospital administrators to securely archive medical documents without printing.

Each digital signature is backed by an Electronic Certificate issued by VIDA as a licensed Certificate Authority (PSrE).

This certificate functions as an official digital identity — similar to a digital ID card or electronic company seal — and contains important details such as:

  • The signer’s name

  • Public key (for encryption)

  • Certificate validity period

  • Certificate issuer information

To obtain an electronic certificate, users must complete identity verification (eKYC). Once verified, they can perform multiple signatures within the active validity period of their certificate.

Digitalizing medical records cannot be separated from legal and security aspects. By adopting VIDA’s certified digital signature, hospitals and healthcare institutions can:

  • Improve service efficiency

  • Strengthen patient data protection

  • Ensure full compliance with government regulations

In short, VIDA’s digital identity solutions help the healthcare sector build a secure, transparent, and legally compliant digital medical ecosystem.