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DAFTAR ISI

Hal

KATA PENGANTAR............................................................................................. iDAFTAR ISI........................................................................................................... ii

BAB I PENDAHULUAN.......................................................................... 1A. Latar Belakang Rekam Medi................................................... 1

B. R!ang Lingk!".......................................................................... #

1. Fala$a% Rekam Medi........................................................ #

&. Pengertian Rekam Medi.................................................... '(. T!)!an Rekam Medi.......................................................... '

*. +ii, Mii, M-tt- Rekam Medi..........................................

#. Keg!naan Rekam Medi.....................................................

/. Bataan 0"erai-nal.................................................................. D. Landaan H!k!m......................................................................

1. A"ek Per2aratan H!k!m.................................................. 11&. Pemilikan Rekam Medi..................................................... 1&

(. Kera%aiaan Rekam Medi................................................. 1*

*. Peret!)!an Tindakan Medi............................................... 1##. Pem3erian In$-rmai Ke"ada 0rang 4 Badan 5ang

Menda"at K!aa.................................................................. 16

'. Rekam Medi Di Pengadilan.............................................. &1

E. Ke3i)akan Dan Pr-ed!r Rekam Medi.................................... &(1. Ke3i)akan De"ke Tentang Ped-man 0rganiai RS

Terkait Dengan K-mite 7Permenke RI N-. 18*#4MENKES4PER4&88'........................................................................... &(&. Ke3i)akan Identi$ikai Paien Rekam Medi...................... &(

(. Ke3i)akan Identi$ikai Ba2i Rekam Medi......................... &*

*. Ke3i)akan Pemilikan dan N-m-r D-k!men Rekam Medi &##. Ke3i)akan Kelengka"an Pengiian D-k!men Rekam

Medi................................................................................... &#

'. Ke3i)akan Keamanan D-k!men Rekam Medi.................. &'

. Ke3i)akan Pem3erian In$-rmai Ii Rekam Medi............. &6. Ke3i)akan Pen2im"anan dan Pem!na%an D-k!men ........ &

. Ke3i)akan Pemin)aman D-k!men Rekam Medi............... &6

18. Ke3i)akan Peret!)!an ata! Pen-lakan 7In$-rmed /-nent9 &11. Ke3i)akan Pengg!naan Sim3-l Dan Tanda K%!!............ (8

1&. Ke3i)akan Internati-nal /lai$i:ati-n -$ Dieae 7I/D9.. (8

BAB II STANDAR KETENAGAAN......................................................... (1

A. K!ali$ikai S!m3er Da2a Man!ia........................................... (1

B. Ditri3!i Ketenagaan............................................................... (&

/ Bagan 0rganiai...................................................................... (*D. Uraian T!ga............................................................................. (#

a. Ke"ala Bagian Rekam Medi.............................................. (#

 3. Pelakana Ur!an Aem3ling Rekam Medi..................... (#:. Pelakana Ur!an K-ding Rekam Medi............................ (#

d. Pelakana Ur!an Indeking Rekam Medi........................ ('

e. Pelakana Ur!an Filling Rekam Medi............................. ('$. Pelakana Ur!an La"-ran Rekam Medi.......................... ('

g. Pelakana Ur!an TPPR; Rekam Medi............................. ('

%. Pelakana Ur!an TPPRI Rekam Medi............................. (E. Uraian ;a3atan........................................................................... (

a. Uraian ;a3atan Ka. Intalai Rekam Medi........................ (

 3. Uraian ;a3atan Pet!ga Penerima Paien............................ *1

:. Uraian ;a3atan Mengentr2 Data Rekam Medi.................. *#d. Uraian ;a3atan Pengari"an Rekam Medi......................... *6

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e. Uraian ;a3atan Peng-la% Klai$ikai Medi7 K-ding I/D9 #1

$. Uraian ;a3atan Statitik Kegiatan Medi 7Pela"-ran9........ #*

g. Uraian ;a3atan Analii Rekam Medi............................... #'

BAB III 0RGANISASI REKAM MEDIS................................................... #

1. Ke3eradaan Intalai Rekam Medi.......................................... #&. Panitia Rekam Medi 4 S!3 K-mite Medi............................... #

1. Tangg!ng ;a<a3.................................................................. #

&. Keangg-taan....................................................................... #(. Tata Ker)a............................................................................ '8

*. H!3!ngan Ker)a.................................................................. '1

(. Dena% dan Standar Failita...................................................... '*

A. Dena% R!ang Intalai Rekam Medi Ra<at Ina".............. '*B. Dena% R!ang Filling 7Pen2im"anan9 Intalai Rekam

Medi Ra<at Ina"............................................................... '*

/. Dena% R!ang TPPR; = Filling 7Pen2im"anan9 Intalai

Rekam Medi Ra<at ;alan.................................................. '#D. Standar Failita Intalai Rekam Medi ........................... '#

BAB I+ TATA LAKSANA PELA5ANAN................................................... '

A. Pela2anan Penda$taran Paien di Intalai Ra<at ;alan............ '

a. Paien Bar!......................................................................... ' 3. Paien Lama........................................................................ '6

A. F!ngi.................................................................................. '6

B. T!ga P-k-k Intalai Ra<at ;alan 7IR;9 Dalam

Pela2anan Rekam Medi..................................................... '/. Dekri"i Kegiatan P-k-k................................................... '

D. D-k!men Dan /atatan 5ang Dig!nakan............................ 8

E. In$-rmai 5ang Di"erl!kan Mana)emen............................. 8B. Pela2anan Penda$taran Paien di Intalai Ra<at Ina"

7Admii-n9............................................................................... 1

A. F!ngi.................................................................................. 1B. T!ga P-k-k URI Dalam Pela2anan Rekam Medi........... 1

/. Dekri"i Kegiatan P-k-k RM Di Unit Ra<at Ina"7URI9. 1

D. D-k!men Dan /atatan 5ang Dig!nakan............................ &

E. In$-rmai 5ang Di"erl!kan Mana)emen............................. (/. Pela2anan Penda$taran Paien di Intalai Ga<at Dar!rat....... (

A. F!ngi.................................................................................. (

B. T!ga P-k-k IGD Dalam Pela2anan Rekam Medi........... (/. Dekri"i Kegiatan P-k-k RM Di Intalai Ra<at Dar!rat *

D. D-k!men Dan /atatan 5ang Dig!nakan............................ #

E. In$-rmai 5ang Di"erl!kan Mana)emen............................. 'D. Pela2anan Rekam Medi Di Intalai Pemerikaan Pen!n)ang '

A. F!ngi.................................................................................. '

B. Dekri"i Kegiatan P-k-k................................................... '

/. D-k!men Dan /atatan 5ang Dig!nakan............................ D. In$-rmai 5ang Di"erl!kan Mana)emen.............................

E. Pela2anan Rekam Medi Bagian Aem3ling...........................

A. F!ngi Aem3ling.............................................................. B. T!ga P-k-k Aem3ling....................................................

/. Dekri"i Kegiatan P-k-k Aem3ling............................... 6

D. In$-rmai 5ang Di"erl!kan Mana)emen............................. 6E. D-k!men Dan /atatan 5ang Dig!nakan............................

F. Pela2anan Rekam Medi Bagian Pengk-dean dan Pengindek

A. F!ngi K-ding = Indeking................................................ B. T!ga P-k-k K-ding = Indeking......................................

/. Dekri"i Kegiatan P-k-k K-ding = Indeking................. 68

D. In$-rmai 5ang D"erl!kan Mana)emen.............................. 68

E. D-k!men Dan /atatan 5ang Dig!nakan............................ 68

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G. Pela2anan Rekam Medi Bagian Pen2im"anan 7Filling9......... 61A. F!ngi Filling...................................................................... 61

B. T!ga P-k-k Filling............................................................ 61

/. Dekri"i Kegiatan P-k-k Filling....................................... 6&D. D-k!men Dan /atatan 5ang Dig!nakan............................ 6&

E. In$-rmai 5ang Di"erl!kan Mana)emen............................. 6&

H. Pela2anan Rekam Medi Bagian Analiing Dan Re"-rting..... 6&

A. F!ngi Analiing Dan Re"-rting......................................... 6&

B. T!ga P-k-k Analiing Dan Re"-rting............................... 6(

/. Dekri"i Kegiatan P-k-k Analiing Dan Re"-rting.......... 6(D. D-k!men Dan /atatan 5ang Dig!nakan............................ 6*

E. In$-rmai 5ang Di"erl!kan Mana)emen............................. 6*

BAB + PENGEL0LAAN SISTEM REKAM MEDIS............................... 6#A. Sitem Identi$ikai Rekam Medi............................................. 6#

1. Sitem Penamaan................................................................ 6#B. Sitem Pen-m-ran Rekam Medi............................................. 6#

1. Pem3erian N-m-r /ara Unit.............................................. 6

/. Sitem Pen2im"anan Rekam Medi.......................................... 661. Sitem Sentraliai.............................................................. 66

&. Sitem Angka Ak%ir............................................................ 66

(. Failita Fiik R!ang Pen2im"anan.................................... 6

*. Pet!n)!k Pen2im"anan........................................................ 6#. Sam"!l Pelind!ng Rekam Medi........................................ 8

D. Sitem Pem!na%an Rekam Medi........................................... 8

1. Peren:anaan Ter%ada" Rekam Medi 5ang Tidak Akti$..... 8A. Pen2!!tan.................................................................... 1

B. ;ad<al Reteni Ari" 7;RA9.......................................... 1

/. Tata /ara Penilaian Berka Rekam Medi DalamPr-e Pem!na%an....................................................... &

D. Pr-ed!r Penilaian Berka Rekam Medi..................... &

&. Pem!na%an Ari"............................................................... (

E. Sim3-l Dan Tanda K%!!........................................................ *F. Pen2eleaian Dan Pengem3alian Rekam Medi....................... #

G. Perekam Kegiatan Pela2anan Medi......................................... #

1. Penangg!ng ;a<a3 Pengiian Rekam Medi...................... #&. Pen:atatan 7Re:-rding9....................................................... #

(. Berka Rekam Medi.......................................................... 6

a. Ringkaan Ma!k dan Kel!ar.......................................  3. Anamnee dan Pemerikaan Fiik................................ 188

:. Lem3ar Gra$ik............................................................... 181

d. Per)alanan Pen2akit, Intr!ki D-kter, Dan Peng-3atan 181

e. /atatan Perkem3angan.................................................. 18&$. /atatan Pera<at 4 Bidan................................................ 18&

g. Hail Pemerikaan La3-rat-ri!m 4 R-ntgen................. 18(

*. Ketent!an Pengiian Berka Rekam Medi........................ 18*#. Peng-la%an Data Medi...................................................... 18#

1. Perakitan 7Aem3ling9 Rekam Medi......................... 18#

&. K-ding 7:-ding9............................................................ 18(. Indeking....................................................................... 186

a. Indek Paien.......................................................... 186

 3. Indek Pen2akit 7Diagm-i9 dan 0"erai.............. 18:. Indek D-kter.......................................................... 118

d. Indek Kematian..................................................... 118

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'. Tata /ara Pengam3ilan Kem3ali Rekam Medi................. 111

1. Pengel!aran Rekam Medi........................................... 111

&. Pet!n)!k Kel!ar 70!tg!ide9.......................................... 111(. Ketent!an Dan Pr-ed!r Pen2im"anan Lainn2a.......... 11&

*. Ditri3!i Rekam Medi............................................... 11(

BAB +I L0GISTIK...................................................................................... 11*

BAB +II KESELAMATAN KER;A.............................................................. 11#

BAB +III PENGENDALIAN MUTU............................................................. 11

BAB I> PENUTUP....................................................................................... 11

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