7. Spo Pengisian Rekam Medis

STANDAR STANDAR PROSEDUR OPERASIONAL PENGISIAN REKAM MEDIS

 Nomor :

Revisi :

Halaman

086/RSU KU/ Dir/

0

3

SPO/ III/ 2014 Di"e"a$%an& Tanal Ter!i" :

SPO

Direktur RSU Kertha Usada

12 #are" 2014 dr. Gede Handra PK 

PENGERTIAN

Penisian re%am me'is a'ala( "a"a )ara 'alam men*lis re%am me'is +an

TUJUAN

'ila%sana%an ole( 'o%"er 'an s"a,, me'is lainn+a.ar .ar "er)i "er)i$" $"aa %eser %esera aam aman an 'ala 'alam m $en* $en*li lisan san re%am re%am me'i me'iss se(in se(in aa

KEBIJAKAN

mem$erm*'a( 'alam mene"a(*i %on'isi $asien1- SK Dire%"*r No- :

PROSEDUR 

1.

Pen%aian 'o%"er& $eraa" 'an $ra%"isi %ese(a"an lainn+a (ar*s

"er)an"*m 'alam re%am me'is 2. Pen%aian aal ole( 'o%"er aa 'i UD 'i)a"a" 'alam R# 02 %el*(an *"ama& "an'a"an'a vi"al& s"a"*s aleri& an*an $erila%*& s%ala n+eri& s%lara "riase 'an R# 02a anamnesis& $emeri%saan ,isi% 'an  $emeri%saan $en*nan aal& 'ianosis aal 'an "era$i aal 3. Pen%aian aal ole( $eraa" 'i UD 'i)a"a" 'alam R# 02 s*m!er in,ormasi anamnesa& )ara& asal mas*%& ria+a" $en+a%i" se%aran 'an 'a(*l*& $en%aian n+eri& $en%aian ,*nsi& $en%aian resi%o a"*(& resi%o 'e%*!i"*s& 'an s"a"*s %e(amilan 'an R# 02a masala( %e$eraa"an 'an eval*asi& $em!erian o!a"/in,*se& "in'a%an& 'an 'is$osisi  $asien4. 5ai $asien +an se!el*m %e r*anan memerl*%an o!servasi 'a(*l* 'i UD& ma%a (asil o!servasi 'i)a"a" 'i R# 04 ole( $eraa" 5. Se!el*m $asien 'ian"ar %e r*anan& ma%a $asien 'ila$or%an 'a(*l* %e DPP ole( 'o%"er aa 'an 'i"*lis 'alam lem!ar R# 07 'enan men*lis%an "anal 'an a%"* $ela$oran 'an (asil la$oran ins"r*%si 'ari DPP ser"a s"em$el R9.D5.K; +an (ar*s 'i"an'a"anani ole( DPP "erse!*" 'alam a%"* 1< 24 am-

6.

R# 07 mer*$a%an )a"a"an $er%em!anan $asien "erin"errasi 'imana 'a$a" 'i"*lis ole( 'o%"er 'an s"a,, me'is lainn+a +an !er%ai"an 'alam

7.

(al $eraa"an $asienSeala $erin"a( lisan ma*$*n via "ele$on (ar*s 'i"*lis 'alam R# 07 a"a"an Per%em!anan Pasien Terin"erasi PPT 'an 'i!eri s"em$el R9.D5.K; +an (ar*s 'i"an'a"anani ole( 'o%"er !ers an%*"an

8.

+an mem!eri ins"r*%si 'alam a%"* 1< 24 am Seala %el*(an !ar* +an 'ialami $asien& "an'a vi"al& $emeri%saan +an a%an 'ila%*%an 'an (asil $emeri%saan +an "ela( 'ila%*%an ser"a  $eno!a"an +an 'i'a$a" $asien 'i"*lis 'i 'alam lem!ar R# 07 "erse!*"

 !ai% ole( DPP& 'o%"er a"a*$*n s"a, %linis lainn+a9. Do%"er +an 'i'eleasi%an ole( DPP via "ele$on ai! men*lis%ann+a 'i lem!ar R# 07 se!aai !*%"i "er"*lis 'enan melam$ir%an (ari& a%"*& nama 'an "an'a "anan ser"a s"em$el R9.D5.K;10. Seala %ema*an ma*$*n %em*n'*ran $a'a $asien se"ia$ (ari 'i)a"a"  !er'asar%an assessmen" *lan ole( DPP 'an assessmen" "er!ar* +an 'i'a$a" (ar*s selal* 'i"*lis 'i R# 07 11. Hasil $emeri%saan la!ora"ori*m& ra'ioloi& 's! 'i"em$el 'i R# 0=& (asil 9K 'i"em$el 'i R# 0=a ole( $eraa" UD 12. Selan*"n+a !ila a'a %ons*l %e !aian lain ma%a DPP a"a* 'o%"er +an 'i'eleasi%an men*lis%an $ermo(onan %ons*l"asi 'i lem!ar %os*l"asi +an "ela( 'ise'ia%an 13. Peraa" UD melen%a$i me'i%asi 'i R# 06 14. R# 0303! 'iisi ole( $eraa" r*anan saa" $asien 'i"erima 'i r*anan raa" ina$ 15. Peraa" r*anan ai! menisi R# 08 se!aai !*%"i "er"*lis (asil  $en*%*ran vi"al sin $asien se"ia$ (ari 16. Pem!erian KI9 %e$a'a $asien 'an %el*aran+a 'ila%*%an ole( DPP +an menanani a"a* 'o%"er +an 'i'eleasi%an& 'enan "o$i% +an 'iinin%an a"a* +an !el*m 'imener"i se$er"i $en+a%i"& %esem!*(an& n*"risi $asien& %e$ara(an / %om$li%asi& o!a" / "in'a%an me'is 'an lainn+a& 'i"*lis 'i ,orm KI9 'an 'i"an'a"anani ole( $em!eri 'an  $enerima in,omasi 17. Tin'a%an 'ianos"i% se$er"i %a"e"erisasi an"*n& en'os%o$i 'an "in'a%an invasive lainn+a +an a%an 'ila%*%an (ar*s 'ielas%an 'a(*l* %e$a'a  $asien 'an %el*ara ole( DPP +an menanani 'an 'i)a"a" 'alam lem!ar KI9 'i R# 11

18.

UNIT TERKAIT

Hasil "in'a%an +an 'ila%*%an (ar*s 'i"*lis 'alam lem!ar R# 07 ole(

DPP +an menanani 19. Saa" $em*lanan $asien& DPP men*lis res*me $em*lanan $asien 1- UD 2- Raa" ina$ 3- >a!ora"ori*m 4- i?i 7- Re(a!ili"asi #e'i%