Panduan Perlindungan Privasi 2014

8/18/2019 Panduan Perlindungan Privasi 2014

1/13

PANDUAN

PERLINDUNGAN PRIVASI

RS. BAPTIS BATU TAHUN 2014

RS BAPTIS BATU

JL RAYA TLEKUNG NO 1

JUNREJO – BATU


2/13

DAFTAR ISI

Halaman Juul ................................................................................................................ !

Da"#a$ I%! ......................................................................................................................... !!

L&m'a$ P&n(&%a)an ........................................................................................................ !!!

BAB I. P&na)uluan ....................................................................................................... 1

1.1. La#a$ B&la*an( ......................................................................................................... 1

1.2. Tu+uan ...................................................................................................................... 2

1.,. P&n(&$#!an ................................................................................................................ 2

BAB II. Ta#a La*%ana ..................................................................................................... ,

2.1. R&*am -&!% ........................................................................................................... ,

2.2. P&laanan P$!/a%! Pa%!&n.......................................................................................... 4

BAB III. D*um&n#a%! ....................................................................................................

BAB IV. P&nu#u ............................................................................................................ 3

Lam!$an 1 ......................................................................................................................

Lam!$an 2 ...................................................................................................................... 5

DA6TAR PUSTAKA ..................................................................................................... 10

!!


3/13

NAMA

LEMBAR PENGESAHAN

PENGESAHAN DOKUMEN RS. BAPTIS BATU

KETERANGAN TANDA TANGAN TANGGAL

D$(. Ha$! Pu+ Nu($)7-H.K&%. P&m'ua# D*um&n

D$. Imanu&l E*a Tan#au#$a Au#)$!8& P&$%n

D$. A$)9!na PA7S.K6R.7-ARS. D!$&*#u$ RS. Ba#!% Ba#u

!!!


4/13

1.1. Latar Belakang

BAB I

PENDAHULUAN

Hal %!a $an( un#u* m&naa#*an &laanan *&%&)a#an !+am!n l&) Unan( –

Unan(. Dalam m&naa#*an &laanan *&%&)a#an %&:a$a #!mal a$! &n&l&n((a$a

&laanan *&%&)a#an7 %!a $an( '&$)a* a#a% $a)a%!a *n!%! *&%&)a#an $!'a!na an(

#&la) !*&mu*a*an *&aa &n&l&n((a$a &laanan *&%&)a#an. Dalam *n%& &laanan

*&%&)a#an !*&nal !%#!la) $!/a%!7 *&$a)a%!aan an *&amanan.

a. P$!/a%! aala) )a* %&%&$an( un#u* m&n(n#$l a*%&% !n"$ma%! a#a% $&*am m&!%

*&%&)a#an $!'a!na.

'. K&$a)a%!aan ;:n"!&n#!al!#< aala) $#&*%! #&$)aa $&*am m&!% *&%&)a#an an

!n"$ma%! la!n a%!&n &n(an :a$a m&n+a(a !n"$ma%! $!'a! a%!&n an

&laananna.

Dalam &laanan *&%&)a#an7 !n"$ma%! !#u )ana !'&$!*an *&aa !)a* – !)a*

an( '&$9&nan(. In"$ma%! a*an !'&$!*an a#a% &$%u+uan a%!&n.

:. K&amanan ;%&:u$!#< aala) &$l!nun(an #&$)aa $!/a%! %&%&$an( an

*&$a)a%!aan $&*am *&%&)a#anna. K&amanan m&$ua*an $#&*%! #&$)aa

!n"$ma%! &laanan *&%&)a#an an( $u%a*7 )!lan( a#au &n(u'a)an a#a a*!'a#

ula) !)a* an( #!a* '&$#an((un(+a9a'.

. A*%&%7 "l&*%!'!l!#a% #&$)u'un( &n(an '&$'a(a! %um'&$ a &"!%!&n%!

In"$ma%! #&n#an( !&n#!#a%7 !a(n%a7 $!9aa# &na*!#7 $!9aa# &m&$!*%aan an $!9aa#

&n('a#an aa# !'u*a alam )al =

a. Un#u* *&&n#!n(an *&%&)a#an a%!&n.

'. -&m&nu)! &$m!n#aan aa$a#u$7 $n$(a* )u*um alam $an(*a &n&(a*an

)u*um.

:. P&$!n#a) &n(a!lan7 &$m!n#aan an a#au &$%u+uan a%!&n %&n!$!.

. P&$m!n#aan !n%#!#u%! a#au l&m'a(a'&$a%a$*an *&n#uan &$unan( –

unan(an.

&. Un#u* *&&n#!n(an &n&l!#!an7 &n!!*an an au!# m&!%7 %&an+an( #!a*

m&n&'u#*an !&n#!#a% a%!&n.


5/13

1.2. Tuuan.

T&$la*%anana &$l!nun(an 'a(! $!/a%! a%!&n ! Ruma) Sa*!# Ba#!% Ba#u %&:a$a

#!mal &n(an m&l!nun(! )a*>)a* a%!&n #&$)aa $!/a%! an m&n+a(a *&$a)a%!aan

*&%&)a#anna.

S&'a(a! a:uan 'a(! *#&$7 *#&$ (!(!7 #&na(a *&%&)a#an #&$#&n#u7 u(a% &n(&lla

an !m!nan %a$ana &laanan *&%&)a#an ! Ruma) Sa*!# Ba#!% Ba#u alam )al m&l!nun(!

an n()$ma#! )a* %!a $an( a*an *&$a)a%!aan *n!%! *&%&)a#anna. S&'a(a! &l!nun(

a#au $#&*%! *&amanan 'a(! u(a% $&*am m&!% an !n"$ma%! #&n#an( a%!&n.

1.!. Pengert"an.

In"$ma%! #&n#an( !&n#!#a%7 !a(n%a7 $!9aa# &na*!#7 an $!9aa# &n('a#an

a%!&n )a$u% !+a(a *&$a)a%!aanna l&) *#&$7 *#&$ (!(!7 #&na(a *&%&)a#an #&$#&n#u7 u(a% *&%&)a#an &n(&lla an !m!nan %a$ana &laanan *&%&)a#an. S&lu$u) !n"$ma%!

#&n#an( &n('a#an7 &$a9a#an7 *&(!a#an la!nna )a$u% !+a(a *&$a)a%!anna %&&$#! an(

'&$la*u aa a#a $&*am m&!%.

K&$a)a%!anna #&n#an( a%!&n 9a+!' !+a(a l&) %&lu$u) #&na(a *&%&)a#an an m&$&*a

an( %&an( ! alam &n!!*an !%a$ana *&%&)a#an.

1. Pr"#a$%.

Aala) m&n()$ma#! )a* privacy a%!&n

2. &'n(")ent"al"t%.

Aala) *& *&%!aanna un#u* %&lalu m&l!nun(! )a* privacy a%!&n an

*&$a)a%!aanna

!. *era$"t%.

Aala) m&n+un+un( #!n((! *&'&na$an an *&+u+u$an.

2


6/13

2.1. Reka+ Me)",.

BAB II

TATA LAKSANA

a. P&n(am'!lan *um&n $&*am m&!% a$! #&ma# &n!manan )ana aa#

!la*u*an l&) u(a% $&*am m&!%

'. P&m!n+aman *um&n $&*am m&!% l&) u(a% m&!% ! alam $uma) %a*!#

)a$u% !%&$#a! "$mul!$ &m!n+aman an( !#ana#an(an! l&) &m!n+am a#au

&n(am'!l %&$#a u(a% $&*am m&!% an( m&n&$a)*an *um&n.

:. P&m!n+aman *um&n $&*amm&!% l&) u(a% m&!% ! lua$ $uma) %a*!# %&$#a

ma)a%!%9a )a$u% m&n(a+u*an &$m)nan #&$#ul!% *&aa D!$&*#u$ Ruma) Sa*!#

Ba#!% Ba#u.

. P&m!n+aman *um&n $&*am m&!% l&) !n%#an%! ! lua$ $uma) %a*!# ;&n(a!lan

a#au *&l!%!an< )a$u% !%&$#a! &n(a+uan #&$#ul!% l&) !n%#an%! '&$%an(*u#an

*&aa D!$&*#u$ an &n&a)anna !%&$#a! '&$!#a a:a$a.

&. P&$m!n#aan %al!nan a#au "# : !%! *um&n $&*am m&!% l&) a%!&n a#au

*&lua$(ana )a$u% !%&$#a! &n(a+uan #&$#ul!% *&aa D!$&*#u$ %&$#a

m&nana#an(an! &$na#aan *&$a)a%!aan !%! $&*am m&!% an &n&$a)anna

!%&$#a! '&$!#a a:a$a.

". S!a lam'a$ )a%!l "#: *um&n $&*am m&!% an( !'&$!*an *&aa !)a*

lua$ )a$u% !#ana#an(an! l&) &+a'a# an( m&m'a9a)! !n%#an%! R&*am -&!%

a#au K&ala B!an( P&nun+an( -&!% an !'&$! %#&m&l $uma) %a*!#.

(. O$an( #ua 'a$u ana* a%! m&n&$!ma )a* %&'a(a! $an( #ua a%l! '&$)a* un#u*

m&m&$!*%a *um&n $&*am m&!% ana* an(*a#na )!n((a &9a%a7 *&:ual!

*um&n $&*am m&!% ma%a lamau an( '&$*a!#an &n(an $an( #ua a%l!na.

). P&n!manan a#a $&*am m&!% !la*u*an %&:a$a %&n#$al!%a%! ! In%#ala%! R&*am

-&!% !%!man alam l&ma$! #&$*un:!.

!. T&$*a!# *&amanan *um&n $&*am m&!% %&la!n u(a% #!a* !&$*&nan*an

ma%u* *& $uan( &n!manan *um&n $&*am m&!%

+. -&la*u*an %uma) un#u* u(a% $&*am m&!% an( '&lum m&n&mu)

&n!!*an D, R&*am -&!%7 %&an(*an un#u* ma)a%!%9a m&la*u*an *n"!$ma%!

&n(an !)a* !n%#!#u%! &n!!*an un#u* %uma) $"&%!na.

,


7/13

*. A*%&% !n"$ma%! $&*am m&!% )ana !&$'l&)*an *&aa $an( an(

'&$)u'un(an lan(%un( &n(an &laanan a%!&n %&$#a *#&$7 &$a9a#7 #&na(a

*&%&)a#an la!n.

2.2. Pela%anan Pr"#a," Pa,"en.

a. T!a* m&ma%an( aan nama a%!&n !%!a !n%#ala%! $a9a# !na.

'. P&$a9a# m&la*u*an %&$a) #&$!ma !na% ! *an#$ &$a9a# an aa %aa# *&l!l!n(

$uan(an '&$%!"a# *n"!$ma%! *&aa a%!&n.

:. P&$a9a# $a9a# !na m&n!man a#a $&*am m&!% ;%#a#u% a%!&n< ! l&ma$! a#au

la:! an( aman.

. Pa%a %aa# *#&$ /!%!#& an m&la*u*an &m&$!*%aan "!%!* #a m&n+a(a $!/a%!

a%!&n &n(an =

1. -&m!n#a &nun((u a%!&n a#au $an( an( %&an( '&$*un+un( un#u*

*&lua$ %&'&n#a$ *a$&na *#&$ a*an m&m&$!*%a a%!&n.

2. -&nu#u *$&n a#au &n&*a# *ama$.

,. -&m!n#a !+!n *&aa a%!&n un#u* m&la*u*an &m&$!*%aan "!%!* an

m&ma*a!*an %&l!mu#.

&. -&n&!a*an #&ma# a#au $uan(an un#u* *n%ul#a%! an#a$a a%!&n a#au *&lua$(a

&n(an *#&$ ;! $uan( *n%ul#a%! *#&$7 $uan(an *&ala $uan(an


8/13

m&naa#*an !n"$ma%! *&%&)a#an a%!&n %&lama ! $uma) %a*!#< 'a!* $a9a# +alan

mauun $a9a# !na.

*. -&la*u*an &m'a#a%an +am '&$*un+un(.

l. Un#u* a%!&n &n(an *n!%! #&$m!nal a#au (au) (&l!%a) '!la aa *ama$ *%n(

!!na)*an *& *ama$ #&$%&'u#7 '!la #!a* aa7 !'&$!#a)u*an *&aa *&lua$(a

a%!&n an( la!n un#u* m&n+a(a 1;%a#u< $an( %a+a an( aa ! alam $uan(an.

m. B!la aa #&lu%u$ *a%u% %&&$#! un#u* *&&n#!n(an a*$&!#a%! a#au &n&l!#!an7 9a+!'

m&m!n#a !+!n *&aa a%!&n un#u* *&%&!aana !#&lu%u$. P!)a* an(

'&$*&&n#!n(an m&m'ua# &$na#aan %&:a$a #&$#ul!% un#u* m&n+a(a *&$a)a%!aan

a#a $&*am m&!% a%!&n.

n. P&l!u#an l&) m&!a :a* mauun &l&*#$n!* )a$u% m&n(a+u*an &$m)nan

*&aa D!$&*#u$ Ruma) Sa*!# %&:a$a #&$#ul!% an )a$u% m&naa# !+!n a$! a%!&n.

Pa%!&n 9a+!' m&n(!%! "$mul!$ &l&a%an !n"$ma%! *&aa m&!a #&$%&'u#7 &n(an

&m!*!an Ruma) Sa*!# #!a* '&$#an((un(+a9a' #&$)aa *&$a)a%!aan a#a $&*am

m&!% a%!&n.

. Aa'!la !+uma! aa &l!u#an 9a$#a9an ! a$&a $uma) %a*!#7 #&$ma%u* aa %aa#

+am '&$*un+un( ! !n%#ala%! P&laanan In#&n%!" ma*a &$a9a# a#au %a#uan

&n(amanan '&$9&nan( m&nana*an !+!n a$! D!$&*#u$ Ruma) Sa*!# an !+!n a$!

a%!&n7 aa'!la #!a* aa !+!n a$! *&uana7 u(a% $uma) %a*!# 9a+!' m&la$an(

an m&n()&n#!*an &l!u#an %&$#a m&m!n#a 9a$#a9an m&n!n((al*an $uma) %a*!#.


9/13

BAB III

DOKUMENTASI

1. P&n:a#a#an an &la$an !la*u*an l&) %&lu$u) &n&l&n((a$a Ruma) Sa*!#

Ba#!% Ba#u &n(an m&n((una*an "$ma# an( %ua) !%&!a*an l&) R&*am

-&!%.

2. S&lu$u) &$m!n#aan *um&n a%!&n un#u* *&&$luan a%u$an%!7 &n!!*an &n(an

m&n((una*an "$ma# &$m!n#aan *um&n an( !#u+u*an *&aa D!$&*#u$

Ruma) Sa*!# Ba#!% Ba#u.

,. S&lu$u) !%!an *um&n $&*am m&!% !%!man ! !n%#ala%! R&*am -&!% an

!%&$a)*an alam 9a*#u 2 24 +am '!la m&mun(*!n*an.

4. Aa'!la &$m!n#aan *um&n $&*am m&!% !la*u*an l&) $an( an( 'u*an

m&$ua*an *&lua$(a &*a# a#au 9al! a%!&n ma*a )a$u% m&n((una*an Su$a#

Kua%a.

. D*#&$ m&n+&la%*an #&n#an( !n"$ma%! *&%&)a#an a%!&n *&aa *&lua$(a &*a#

a#au 9al! an !la*u*an &n:a#a#an ! L-RM !.

. Bu*#! 'a)9a $uma) %a*!# m&l!nun(! $!/a%! a%!&n !*um&n#a%!*an alam

"$mul!$ &$l!nun(an $!/a%!.

3. A#a% %&!+!n a%!&n !n"$ma%! *&%&)a#an )ana !'&$!*an *&aa $an( an( #&la)

!#un+u* l&) a%!&n7 !*um&n#a%!*an alam "$mul!$ &l&a%an !n"$ma%!.


10/13

BAB I*

PENUTUP

D&n(an !#a*anna Panuan P&laanan P$!/a%! Pa%!&n ma*a %!a &n&l&n((a$a

*&%&)a#an an( #&$!$! a$! #&na(a m&!%7 ma)a%!%9a $a*#!*7 ! Ruma) Sa*!# Ba#!% Ba#u

aa# m&n+a(a $!/a%!7 *&$a)a%!aan !n"$ma%! *&%&)a#an a%!&n &n(an %&'a!* – 'a!*na7 %&$#a

aa# m&n()$ma#! )a* %!&n #&$)aa $!/a%!na.

3


11/13

La+/"ran 1

RUMAH SAK IT BAPTIS BATU

0l. Ra%a Tlekung N'. 1 Batu Tr'+'l P', 1

Tl/. !314 5631718 5691628 56916! Fa:. !314 569611

FORMULIR PERMINTAAN PEMBATASAN PENGUN0UNG

D&n(an !n! %aa m&n(!+!n*an *&lua$(a a#au &n(un+un( a#a% nama =

1. CCCCCCCCCCCCCCCCCCCCCCCCCCCC..


,. CCCCCCCCCCCCCCCCCCCCCCCCCCCC..


Un#u* m&n(un+un(! a#au m&n+a(a %aa*&lua$(a %aa %&lama m&naa#*an &$a9a#an ! RS

Ba#!% Ba#u.

Ba#u7 CCCCCCCCC

Pa%!&nK&lua$(a

Tana #an(anNama T&$an(

Sa*%!

Tana #an(anNama T&$an(


12/13

Nama =

RUMAH SAKIT BAPTIS BATU0l. Ra%a Tlekung N'. 1 Tlekung 0unre' Batu

Tel/. !314 563171 Fa:. !314 569611

PER SETU0UAN PELEPASAN INFORMASI MEDIS

N. R&(!%#&$ =

L

Umu$ = Ruan( = Lan#a! =

P

N. R&*am -&!* =

Yan( '&$#ana #an(an ! 'a9a) !n! =

Nama

T(l. La)!$ K&lam!n

N. Ka$#u I&n#!#a%

Alama#

=

=

=

=

Hu'un(an &n(an a%!&n = Suam! I%#$! Ana* Aa) I'u Pa%!&n %&n!$! La!n>

la!nCCCCCCCCCCCCCCCC........

D&n(an !n! m&m'&$! *ua%a *&aa !)a* Ruma) Sa*!# Ba#!% Ba#u un#u* m&m'&$!*an !n"$ma%! m&!% %&:a$a

l!%an an a#au #&$#ul!% m&n(&na! !$! %aa a%!&n

N.

1

2

,4

Nama J&n!%

K&lam!n

T(l. La)!$ Alama#

la'&l

N. T&l Hu'. (n P

P&m'&$! *ua%a #!a* a*an m&nun#u# *#&$ &m'&$! !n"$ma%! ana#au Ruma) Sa*!# Ba#!% Ba#u #&n#an(

%&(ala )al an( '&$*&naan &n(an &m'&$!an !n"$ma%! %&:a$a l!%an an a#au #&$#ul!% !n! !*&mu!an )a$!.

D&m!*!an %u$a# &$%u+uan &l&a%an !n"$ma%! m&!% !n! %aa 'ua# &n(an &nu) *&%aa$an an #ana aa

a*%aan a$! !)a* manaun un#u* !&$(una*an %&'a(a!mana m&%#!na.

Ba#u7CCCCC.CCCCCCP*lCCC=CCC..

P!)a* Ruma) Sa*!# Ba#!% Ba#u

;..CCCCCCCCC..C.< ;..CCCCCCCCC..C.<

P!)a* Pa%!&n

;CCCCCCCCCCCC..<

Nama #&$an(

5

Yan( m&m'&$! *ua%a

;CCCCCCCCCCCC..<

Nama #&$an(

;CCCCCCCCCCCC..<

Nama #&$an(


13/13

DAFTAR PUSTAKA

a&$n!#7 Lna Jual ;2000

Panduan Perlindungan Privasi 2014

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