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  • Pemberian Kode Tindakan/Prosedur Pasien: Rumah Sakit Umum Pusat H.Adam Malik

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    This document provides procedures for coding medical procedures and treatments for patients at H. Adam Malik Central Hospital using ICD-9-CM codes. It outlines 7 steps for medical records staff to follow: 1) Receive medical records from assembling staff, 2) Read the treatment/procedure form to identify any treatments given to the patient, 3) Search for the treatment/procedure code in the ICD-9-CM index, 4) Verify the code in the front of the ICD-9-CM book, 5) Write the ICD-9-CM code on the treatment form, 6) Enter the code into the hospital's computer system, and 7) Pass the completed medical record to storage. The coding aims

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    ICD-9 OK

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    This document provides procedures for coding medical procedures and treatments for patients at H. Adam Malik Central Hospital using ICD-9-CM codes. It outlines 7 steps for medical records staff to follow: 1) Receive medical records from assembling staff, 2) Read the treatment/procedure form to identify any treatments given to the patient, 3) Search for the treatment/procedure code in the ICD-9-CM index, 4) Verify the code in the front of the ICD-9-CM book, 5) Write the ICD-9-CM code on the treatment form, 6) Enter the code into the hospital's computer system, and 7) Pass the completed medical record to storage. The coding aims

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    © All Rights Reserved
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    13 views1 page

    Pemberian Kode Tindakan/Prosedur Pasien: Rumah Sakit Umum Pusat H.Adam Malik

    Uploaded by

    loket kartu 1
    This document provides procedures for coding medical procedures and treatments for patients at H. Adam Malik Central Hospital using ICD-9-CM codes. It outlines 7 steps for medical records staff to follow: 1) Receive medical records from assembling staff, 2) Read the treatment/procedure form to identify any treatments given to the patient, 3) Search for the treatment/procedure code in the ICD-9-CM index, 4) Verify the code in the front of the ICD-9-CM book, 5) Write the ICD-9-CM code on the treatment form, 6) Enter the code into the hospital's computer system, and 7) Pass the completed medical record to storage. The coding aims

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    © All Rights Reserved
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    of 1

    RUMAH SAKIT UMUM PUSAT

    H.ADAM MALIK PEMBERIAN KODE TINDAKAN/PROSEDUR PASIEN

    NO DOKUMEN REVISI HALAMAN


    OT.01.01/IV.5/18/2014 2 1/1

    PROSEDUR TETAP TANGGAL TERBIT Ditetapkan


    Direktur Utama
    4 September 2014
    INSTALASI REKAM MEDIS
    Dr. Lukman Hakim Nasution,, Sp.KK
    NIP : 195411201984031004
    Suatu kegiatan pemberian kode ICD-9-CM terhadap
    PENGERTIAN tindakan/prosedur pasien.

    1. Untuk memudahkan pelayanan pada penyajian


    TUJUAN informasi
    2. Untuk menunjang fungsi perencanaan manajemen
    dan riset bidang kesehatan
    KEBIJAKAN SK Direktur Utama No : DM.01.12/IV.2/1118a/2014
    Tentang Kebijakan Pengelolaan dan Peyelenggaraan
    Rekam Medis
    PROSEDUR 1. Petugas menerima rekam medis dari petugas
    assembling
    2. Membaca tindakan/prosedur formulir RM04/
    RM08/Formulir gawat darurat apakah ada tindakan
    yang diberikan kepada pasien
    3. Mencari kode tindakan/prosedur pada indeks ICD-9-
    CM
    4. Cek kebenaran pada buku ICD-9-CM bagian depan
    5. Menulis kode ICD-9-CM pada formulir RM04/RM08/
    formulir gawat darurat
    6. Mengentrikan kode tindakan/prosedur ke Komputer
    SIM-RS sesuai aplikasi
    7. Rekam medis yang telah siap diserahkan kebagian
    penyimpanan

    SE. DIRJEN BINA YANMED

    1. Instalasi Rawat Jalan


    UNIT TERKAIT 2. Instalasi Rawat Inap
    3. Instalasi Gawat Darurat

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