MEDICAL RECORD FOR

FAMILY PRACTITIONER
Disampaikan
oleh
Wahyudi Istiono
Acuan
Noviayanti Petto1, Wahyudi Istiono2
1
Rekam Medis dan Informasi Kesehatan, FMIPA UGM, Yogyakarta
2
Bagian Ilmu Kesehatan Masyarakat, FK UGM, Yogyakarta
Background:
 National Health System declared that
primary health care system on future will
be executed with implementation family
doctor concept.
 (Yogyakarta), way of implementation by
cooperation between Municipality Health
0ficce of Yogyakarta with the School
Medicine University of Gadjah Mada to
training the family doctor certificate
Background (cont):
 JAMKESDA (Jaminan Kesehatan
Daerah) conduct source of finance will
be support budgeting health system
through training block 1 (cover all
material of Paket A & B) for 4 month.
 Block 1 is part of block 2, 3, 4, and
elective block running for two years.
Back ground (Cont):
 Compliance executing practice of family
doctor, designer wish to design special
medical record of family doctor. This
medical record is very necessity for
social data record and medical data
record of patient in practice of medical
record.
Target:
 Design the medical record in practice of family
doctor to support the elementary principle
family doctor service and authority doctor by
emphasize content aspect which adapted
condition in practice of family doctor.
Process :
 Subjek Researcher select three medical record
models
 The result made base by a designer to design the
medical record of family doctor and also supported
with the theory of design and medical record.
 Result of choice re-designed by adding and
lessening item which adapted by condition in
practice of family doctor.
 Designer make the alternative design and give to
subjek researcher for selected again so designer
get the selected design and make realization the
medical record of family doctor.
Acuan Design
 Health Information Form for Adult and
Children (American Health Information
Management Association/ AHIMA)

 Family Health and Medical Record (The

Texas A&M University System)

 Formulir Rekam Medis Rawat Jalan

(Departemen Kesehatan RI).
Result :
 Based on three medical record models, four component POMR (Problem Oriented Medical Record) and
opinion from subjek researcher
medical record of family doctor consists of:
 the Patient’s Identity,
 Health Care Provider’s Identity,
 Medical History,
 Allergic History,
 Life Style,
 Immunizations,
 Hospitalization History,
 Operation History,
 Disease of Family Member History,
 Family Genogram,
 Problem List of Patient,
 Progress Notes of Patient and Diagram of Progress Disease.
Hasil Analisis medical record
 Health Information Form (AHIMA, 2006)
formulir informasi kesehatan untuk
anak-anak (Health Information Form
for Children)

formulir informasi kesehatan untuk

dewasa (Health Information Form
for Adult).
Health Information Form for
Children
 Identification dan Birth Data;
 Health Log dan Allergies/ Drug
Sensitivities;
 Medications;
 Infectious Diseases dan
Immunizations;
 Growth and Development Information.
Health Information Form for Adult
(15 form)
 Identification dan Emergency Contacts;
 Healthcare Providers;
 Insurance Providers;
 Legal Documents/ Medical Directives;
 Medical History dan Infectious Diseases;
 Immunizations dan Allergies/ Drug Sensitivities;
 Family Member History;
 Lifestyle dan Health Log;
 Medications;
 Doctor Visits;
 Hospitalizations;
 Surgeries;
 Lab or Imaging dan Medical Devices;
 Physical/ Occupational Therapy;
 Vision dan Dental.
Family Health and Medical Record (The Texas A&M
University System, 1998)

 Introduction;
 Health Care Providers dan Health Insurance Policies;
 Your Family Health History;
 Spouse’s Family Health History;
 Adult Health Information;
 Adult Immunization Record;
 Children’s Birth Information dan Children’s Growth
Information;
 Childhood Immunization Record;
 Childhood Diseases dan Major Illness or Surgery;
 Accidental Injury Record dan Allergy/ Sensitivity Record;
 Medical and Dental Checkups;
 Medications; Questions I Want to Ask the Doctor;
 Notes.
Formulir Rekam Medis Rawat Jalan Rumah Sakit
(Departemen Kesehatan RI)

 Data identitas pasien ini berisikan:

 alamat, telepon, umur, jenis kelamin, agama,
pekerjaan, nama ayah, nama ibu, rujukan dari,
perubahan alamat.

Data medis pasien yakni tanggal kunjungan,

poliklinik yang dikunjungi, diagnosis,
tindakan/operasi, dan tanda tangan dokter/
poliklinik/ operasi.
Hasil rancangan ulang rekam medis dokter keluarga
pilihan terdiri dari:

 RM. 1a :
 Identitas Pasien, Identitas Penyedia Layanan Kesehatan,
Riwayat Penyakit Dahulu, Riwayat Alergi, dan Gaya
Hidup;
 RM. 1b :
 Imunisasi, Riwayat Rawat Inap, dan Riwayat Operasi;
 RM. 1c :
 Riwayat Penyakit Anggota Keluarga dan Pohon Keluarga;
 RM. 1d : Daftar Masalah Pasien;
 RM. 2 :
 Catatan Perkembangan Pasien; dan
 RM. 3:Diagram Perkembangan Penyakit.
 
KESIMPULAN
 Berdasarkan empat komponen POMR (Problem
Oriented Medical Record), tiga model rekam medis
dan kumpulan pendapat dari subjek peneliti maka
hasil rancangan rekam medis dokter keluarga
terdiri dari:
 RM. 1a : Identitas Pasien, Identitas
Penyedia Layanan Kesehatan, Riwayat Penyakit
Dahulu, Riwayat Alergi, dan Gaya Hidup;
 RM. 1b : Imunisasi, Riwayat Rawat Inap,
dan Riwayat Operasi;
 RM. 1c : Riwayat Penyakit Anggota
Keluarga dan Pohon Keluarga;
 RM. 1d : Daftar Masalah Pasien;
 RM. 2 : Catatan Perkembangan Pasien;
dan
 RM. 3 : Diagram Perkembangan
Penyakit.
Saran (RM MANUAL)
 Gunakan map untuk menyimpan rekam
medis secara keseluruhan agar lebih aman
dan rahasia;
 Penyimpanan berkas rekam medis dokter
keluarga sebaiknya 1 berkas rekam medis
1 pasien sehingga dapat meminimalkan
kesalahan pengambilan lembar rekam
medis antar keluarga
 Perlu diteliti dan dikembangkan RM dalam
model Elektronik medical record untuk
Family Practioner yang interactive dan
comprehensive dan professional.
Kepustakaan
 KEPUSTAKAAN
 AHIMA. 2006. Health Information Form For Adult. Formulir.
Diakses tanggal 7 Oktober 2007 jam 2:19 PM dari
http://www.myphr.com/your_record/adultform.pdf.
 AHIMA. 2006. Health Information Form For Children.
Formulir. Diakses tanggal 7 Oktober 2007 jam 2:23 PM dari
http://www.myphr.com/your_record/childform.pdf.
 Azwar, A. 1996. Pengantar Administrasi Kesehatan Edisi
Ketiga. Jakarta: Binarupa Aksara.
 Barry, S. 2006. Merancang Itu Gampang Kumpulan Catatan
Pengantar Disain. Yogyakarta: FSR ISI.
 Departemen Kesehatan RI. 1997. Pedoman Pengelolaan
Rekam Medis Rumah Sakit Di Indonesia Revisi I. Jakarta:
Direktorat Jenderal Pelayanan Medik DepKes RI.
 Departemen Kesehatan RI. 2004. Sistem Kesehatan
Nasional. Jakarta: Menteri Kesehatan Republik Indonesia.
Kepustakaan (CONT.)
 Departemen Kesehatan RI, IDI, dan FK-UI. 2007. Pelayanan
Kedokteran Keluarga dan JPKM. Diakses tanggal 30
Oktober 2007 jam 7:36 PM dari
http://www.depkes.go.id/index.php.htm.
 Family Meidicine. 2007. Family Medicine Postgraduate.
Diakses tanggal 15 April 2008 jam 8:43 PM dari
http://www.family medicine.ugm.ac.id/postgraduate.php.htm.
 Gan, G. L., Azwar, A., dan Wonodirekso, S. 2004. A Primer
On Family Medicine Practice. Singapore: Singapore
International Foundation.
 Haryanti, A. B. 2004. Evaluasi Format Formulir Ringkasan
Masuk dan Keluar Pasien di PKU Muhammadiyah Bantul
Yogyakarta. Karya Tulis Ilmiah (tidak dipublikasikan).
Yogyakarta: Fakultas Matematika dan Ilmu Pengetahuan
Alam Universitas Gadjah Mada.
Kepustakaan (cont.)
 Kadir, A., dan Terra CH. Triwahyuni. 2003. Pengenalan Teknologi Informasi.
Yogyakarta: ANDI.
 Konsil Kedokteran Indonesia. 2006. Manual Rekam Medis. Jakarta: Konsil
Kedokteran Indonesia.
 Maulana, A. 2004. Kamus Ilmuah Dengan EYD Dan Pembentukan Istilah
Serta Akronim Bahasa Indonesia. Yogyakarta: Absolut.
 Minhaj, K. 2004. Rancangan Formulir Persetujuan Tindakan Medis
(Informed Consent) di RSUD Dr. Soeradji Tirtonegoro Klaten. Karya Tulis
Ilmiah (tidak dipublikasikan). Yogyakarta: Fakultas Matematika dan Ilmu
Pengetahuan Alam Universitas Gadjah Mada.
 Ministry Of Health RI. 2007. Indonesia Health Profile 2005. Jakarta: Ministry
of Health Center for Data and Information.
 Pollard, J., Rice, C., dan Greer, K. 1998. Formulir. Diakses tanggal 27
November 2007 jam 8:01 PM dari
http://fcs.tamu.edu/Health/child_health/family_medical_record/family_medic
al_record.pdf.
 Prawira, N.G. dan Dharsono. 2003. Pengantar Estrtika Dalam Seni Rupa,
164-165. Proyek Peningkatan Penelitian Pendidikan Tinggi Direktorat
Jendral Pendidikan Tinggi Departemen Pendidikan Nasional. Bandung:
STISI.
Kepustakaan (cont)
 Racmawati, D. 2006. Rancangan Berkas Rekam Medis di
BRSD Wonosobo. Karya Tulis Ilmiah (tidak dipublikasikan).
Yogyakarta: Fakultas Matematika dan Ilmu Pengetahuan
Alam Universitas Gadjah Mada.
 Sulistyo dan Basuki. 2003. Manajemen Arsip Dinamis:
Pengantar Memahami Dan Mengelola Informasi Dan
Dokumen. Jakarta: PT Gramedia Pustaka Utama.
 WHO. 2006. Medical Records Manual: A Guide For
Developing Countries. Book. Diakses tanggal 23 November
2007 jam 5:54 PM dari
http://www.wpro.who.int/NR/rdonlyres/7FB74A3F-34F6-
4C46-A9F0-1F0D52D04254/0/MedicalRecordsManual.pdf.
 Wonodirekso, S. 2004. Serba-Serbi Dokter Keluarga: Sistem
Pelayanan Dokter Keluarga. Artikel. Diakses tanggal 30
Oktober 2007 dari http://www.jpkm-
online.net/kolomdokel.php?act=list.