Assembling Rekam Medis

Zainal Arifin
Berkas yang berisikan catatan dan dokumen
tentang identitas pasien, pemeriksaan,
pengobatan, tindakan dan pelayanan lain yang
telah diberikan kepada pasien

Permenkes No 269 Tahun 2008, pasal 1

A patient’s medical record should provide
accurate information on:

• who the patient is and who provided health care;

• what, when, why and how services were
provided; and
• the outcome of care and treatment.

Huffman, 1990
Where Does
the Medical
Record
Begin?
The medical record begins with the patient’s first
admission as an inpatient or attendance as an
outpatient (if a combined medical record) to the
health care facility.
Identifikasi
Pasien &
Penomoran
RM
• Accurate identification of a patient is the
backbone of an effective and efficient medical
record system
• The responsibility for correctly identifying a
patient rests with the clerk who interviews the
patient in the admission office or outpatient
department
Components
of a Medical
Record
The physical medical record will eventually
consist of the following:
• medical record forms;
• a clip or fastener to hold the papers together;
• dividers between each admission and outpatient
notes; and
• a medical record folder.
 Formulir
Rekam Medis
• Lembar depan (lembar identifikasi & summary)  identifikasi,
diagnosa akhir, kode penyakit dan tindakan, dan tanda tangan
dokter;
• Persetujuan tindakan yang harus ditandatangani pasien saat admisi
 a) general consent, b) hak pelepasan informasi
• Dokumen legal & korespondensi tentang pasien  surat rujukan,
permintaan informasi, dll.;
• Ringkasan Pasien Keluar;
• Catatan admisi;
• Catatan perkembangan pasien selama perawatan;
• Catatan perawatan Keperawatan  suhu, nadi, grafik pernafasan,
grafik tekanan darah dll
• Laporan operasi;
• Catatan profesi kesehatan lain;
• Laporan pathology  haematology, histology, microbiology, etc.;
• Laporan lain  X-ray, etc.;
• Tindakan dan pengobatan harian yang ditandatangani dokter dan
perawat; and
• Lembar keperawatan khusus terkait observasi luka bagian kepala
dll.
THE ORDER
OF FORMS AS
LISTED
ABOVE IS
RECOMMEN
Clip atau
Fastener
It is best to use
plastic rather than
metal clips. Metal
clips can
cut fingers
Medical
Record
Dividers
It is good practice to separate each
admission by a divider; the divider
will be slightly wider
than the forms in the medical
record and have a tab on which to
write
“1st Admission”, “2nd Admission”,
etc
Medical
Record
Folder
The following should be written on
the medical record folder:
• patient's name;
• patient's medical record number;
and
• year of last attendance
Proses Pengolahan Rekam Medis
1. Assembling
2. Coding
3. Indexing
4. Health care Statistic & reporting
5. Corresponding
6. Analyzing
7. Filing & Retention