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PANDUAN PELAYANAN REKAM MEDIS UPT PUSKESMAS BATURETNO I TAHUN TAHUN 2016
I.
DEFINISI Rekam kam Medis Medis adalah berka !a"# ber$$ka" %a&a&a" da" d'k()e" 1. Re &e"&a" &e"&a"# # $de"&$ $de"&$&a &a *a$e" *a$e"++ *)er$ *)er$ka kaa"+ a"+ *e"#'b *e"#'ba&a" a&a"++ &$"dak &$"daka" a" da" *ela!a"a" la$" !a"# &elah d$ber$ka" ke*ada *a$e" 2. Nomor Index adalah ,. Tracker adalah -. Dokter r dan dokter dokter gigi gigi adalah el(r(h d'k&er ()() da" d'k&er . Dokte #$#$ !a"# )elak(ka" *rak&ek d$ P(ke)a P(ke)a /$led(#. 6. Tenaga Kesehatan tertentu adalah &e"a#a keeha&a" !a"# $k(& )e)ber$ka" )e)ber$ka" *ela!a"a" keeha&a" e%ara la"#("# ke*ada *a$e".
II.
RUANG I INGKU! A. R(a"# l$"#k(* Pa"d(a" Reka) Reka) Med$ Med$ )e"%ak(* )e"%ak(* 1. S&a Med$ Med$ D'k&er D'k&er da" d'k&er #$#$ 2. S&a S&a Ke*er Ke*eraa aa&a" &a"3B$ 3B$da" da" ,. A*'& *'&eke eker -. Ahl$ hl$ 4$5$ 4$5$ . A"al$ A"al$ Lab'ra Lab'ra&'r &'r$() $() 6. Te"a# e"a#a a keeh eeha& a&a" a" la$" la$" !a"# !a"# )e)b )e)ber er$k $ka" a" *ela *ela!a !a"a "a" " keeh eeha& a&a" a" la"#("#. B. Pa"d(a" Reka) Reka) Med$ Med$ ber$$ ber$$ 1. I$ I$ Rek Reka) a) Med Med$ $ a. I$ M$"$)al M$"$)al Reka) Med$ Med$ ("&(k ("&(k *a$e" *a$e" raa& ala" b. I$ M$"$)al M$"$)al Reka) Med$ Med$ ("&(k ("&(k *a$e" *a$e" #aa& dar(ra& dar(ra& 2. P'la P'la Pe"(l$ Pe"(l$a" a" %a&a&a" %a&a&a" )ed$ )ed$ SOAP ,. Ke#$a&a Ke#$a&a" " !a"# har( d$%a&a& da" d$d'k()e" d$d'k()e"&a$k &a$ka" a" kedala) kedala) berka berka reka) )ed$ *a$e". -. S&a S&a !a"# !a"# d$$5 d$$5$" $"ka ka" " )e"( )e"(l$ l$k ka" a" *er$ *er$"& "&ah ah kedal edala) a) berk berka a reka) eka) )ed$ *a$e".
III.
TATA AKSANANA Dala) *r'e a(ha" *a$e" !a"# &er$"&e#ra$+ keberla"#("#a" k')("$ka$ da" $"'r)a$ )e"#e"a$ k'"d$$ *a$e" da"
*erke)ba"#a""!a *erl( &era#a ("&(k )e"a)$" *ela!a"a"3a(ha" !a"# a)a"ba# a)a"ba#$$ *a$e"+ *a$e"+ ("&(k ("&(k $&( ela)a ela)a *r'e *r'e a(ha" a(ha" raa& raa& $"a*+ $"a*+ *ada *ada k("( k("(#a" #a" raa& raa& ala" ala" a&a( a&a( *ada *ada aa& aa& d$b(&( d$b(&(hka hka" " reka) reka) )ed$ )ed$ har( har( elal( &ered$a. Se&$a* *a$e" !a"# )e"ala"$ *r'e *e"#ka$a"3ae)e" da" ke&$ka elea$ )e"er$)a *ela!a"a"3a(ha" da" *e"#'ba&a" har( d$%a&a& da" d$d'k()e"&a$ka" d$d'k()e"&a$ka" A. Sistem !enomoran !enomoran "Nomor "Nomor Index Rekam Medis# Medis# Pe"')'ra" reka) )ed$ )e"##("aka" 7 d$#$& 899YY:;;;;< 99 YY
= K'd K'de e P(k P(ke e)a )a Ba&( Ba&(rre&"' e&"' 1 !a$ !a$&( &( 0> = K'de l'ka$ l'ka$ *er&a)a kal$ *a$e" d$re#$&ra$ d$re#$&ra$ 01 = P(ke)a P(ke)a I"d(k 02 = P(ke)a Pe)ba"&( Dea Te)'" 0, = P(ke)a P(ke)a Pe)ba"&( Pe)ba"&( Bale*a"a"# 0- = P(kel$"#
;;;;
= N' Ur Ur(& Re Re#$& #$&rra$ e e(a$ de" de"#a" b(k b(k( re re#$&er *a *a$e"
8'&are $)*(<
$. !EN%IM!ANAN !EN%IM!ANAN REKAM MEDIS Reka) )ed$ d$ $)*a" d$r(a"# reka) )ed$ e(a$ *e"')'ra" !a"# &elah d$&e"&(ka" &. Isi Minim Minima' a' Rekam Rekam Medis Medis (. !asie !asien n Ra)at Ra)at *a'an *a'an a. I$ M$"$)al Reka) Med$ Pa$e" Raa& ?ala" Pe"#ka$a"3ae)e" *a$e" raa& ala" !a"# )el$*(&$ ae)e" )ed$ da" ae)e" ke*eraa&a" d$%a&a& dala) le)bar %a&a&a" )ed$ *a$e" raa& ala"+ ek(ra"#:k(ra"#"!a $"'r)a$ !a"# har( &erda*a& dala) reka) )ed$ raa& ala" adalah 1< Ide"&$&a Ide"&$&a Pa$e" Pa$e" )el$* )el$*(&$ (&$ Na)a Na)a le"#ka* le"#ka* da" da" &a"##al &a"##al lah$r@ lah$r@ 2< Ta"##al da" da" ak&( *e"#k *e"#ka$a"@ a$a"@ ,< Ha$l a"a)"e$ a"a)"e$ )e"%ak(* )e"%ak(* ek(ra"#: ek(ra"#:k(r k(ra"#"!a a"#"!a kel(ha" kel(ha" -< < 6< >< 7< <
da" r$a!a& *e"!ak$&@ Ha$l Pe)er$ Pe)er$kaa" kaa" $k@ Ha$l *e)er$k *e)er$kaa" aa" *e"("a"# *e"("a"# )ed$k@ )ed$k@ D$a# D$a#"' "'$ $@ @ Re"%a"a e"%a"a *e"a&al *e"a&alaka aka"aa "aa"@ "@ Pe"#'ba& Pe"#'ba&a" a" da"3a&a da"3a&a( ( &$"dak &$"daka"@ a"@ Pela!a Pela!a"a" "a" !a"# &elah d$ber$ d$ber$ka" ka" ke*ada ke*ada *a$e"@ *a$e"@
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