Medical Record And

Health Information
Technicians
Teacher : Lidia Deviga, S.Pd.,M.Pd
 GROUP 4

Amanda Vetimah Sari Amelia Dina Puspitasari

01 03
Della Dwi Fitrianingsih Devi Dwi Nurfiani

02 04
Devie Listianingtias

05
 Do you know about
MEDICAL RECORD ??
Medical Record is a file or record containing who, what,
why, when, and how the services provided to patients
during the treatment period contain sufficient
information to identify the patient, establish a diagnosis
and treatment and record the results.

Rekam Medis adalah berkas atau catatan yang

memuat siapa, apa, mengapa, kapan, dan bagaimana
pelayanan yang diberikan kepada pasien selama masa
pengobatan berisi informasi yang cukup untuk
mengidentifikasi pasien, menegakkan diagnosis dan
pengobatan serta mencatat hasilnya.
 Then what is a medical
record technician?
Compile, process, and maintain medical records of hospital and clinic patients in a
manner consistent with the medical, administrative, ethical, legal, and regulatory
requirements of the health care system. Medical Records Technicians are also
responsible for reporting patient information for health requirements and standards in a
manner consistent with the disease diagnosis code system for health care.
Menyusun, memproses, dan memelihara catatan medis pasien rumah sakit dan klinik
dengan cara yang konsisten dengan persyaratan medis, administrasi, etika, hukum,
dan peraturan dari sistem perawatan kesehatan. Teknisi Rekam Medis juga
bertanggung jawab untuk melaporkan informasi pasien untuk persyaratan dan standar
CREDITS:
kesehatan dengan Thiscara
presentation template wasdengan sistem kode diagnosis penyakit untuk
yang konsisten
created by Slidesgo,
perawatan kesehatan. including icons by
Flaticon, infographics & images by Freepik

Medical records technicians obtain patient information from

healthcare professionals and convert the data into permanent medical
records. They specialize in standard healthcare coding systems, categorizing
medical information, and updating patient records for doctors and insurance
companies
Medical record technician duties
1. carry out patient service activities in the basic management of medical
records and health information; ( melaksanakan kegiatan pelayanan pasien
dalam pengelolaan dasar rekam medis dan informasi kesehatan)
2. evaluate the contents of medical records; (mengevaluasi isi rekam medis)
3. implement a system of clinical classification and codification of diseases
related to health and medical treatment according to the correct medical
terminology; (menerapkan sistem klasifikasi klinis dan kodifikasi penyakit
yang berkaitan dengankesehatan dan pengobatan menurut istilah medis yang
benar)
4. implement
CREDITS:the This index by template
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was data on diseases, deaths, actions and
doctorscreated
grouped in theincluding
by Slidesgo, index;icons
(melaksanakan
by indeks dengan mengumpulkan
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data penyakit, kematian,& images by Freepik
tindakan dan dokter yang dikelompokkan dalam
indeks)
5. implement a reporting system in the form of information on health service
activities; (menerapkan sistem pelaporan berupa informasi kegiatan pelayanan
Kesehatan)
6. designing the structure of the content and standards of health data, for the
management of health information; (merancang struktur isi dan standar data
kesehatan, untuk pengelolaan informasi Kesehatan)
7. evaluate the completeness of the contents of the diagnosis and action as the
coding accuracy; (mengevaluasi kelengkapan isi diagnosis dan tindakan
sebagai ketepatan pengkodean)
8. carry out data collection, validation and verification according to hospital
statistics; (melakukan pendataan, validasi dan verifikasi sesuai statistik
rumah sakit)
9. recording and reporting surveillance data; (pencatatan dan pelaporan data
surveilans)
10. manage work groups and work unit management and run health service
providers and providers; (mengelola kelompok kerja dan pengelolaan
unit kerja serta menjalankan penyelenggara dan penyelenggara
pelayanan Kesehatan)
 OUTPATIENT
SERVICE Patient Comes
Pasien Datang Outpatient Registration
at the Outpatient
Reception Center
Pendaftaran Pasien
Outpatient Reception Rawat Jalan di Tempat
Center Penerimaan Pasien
Tempat Penerimaan Pasien Rawat Jalan
Rawat Jalan

Medical Support Examination Destined Polyclinic

Medical check up
Pemeriksaan Penunjang Medis Poli Klinik Yang
Pemeriksaan Medis
Dituju

Inpatient Consultation to Other

Rawat Inap Polyclinic or Medical
Rehabilitation
Konsultasi Ke Poli
Medicine Service Klinik Lain atau
Pelayanan Obat Rehabilitasi Medis

Return Payment Counter Refer to Other Hospital

Pulang Loket Pembayaran Rujuk ke Rumah Sakit Lain
Outpatient Flow Explanation
The patient comes then goes to the Outpatient Reception
Place, then the patient registers as a BPJS patient or
General at the Outpatient Registration Place, then the
patient goes to the intended Polyclinic, after that the
patient is called for a medical examination, if at the time
of examination the patient requires medical support
examination, the patient must go to the medical support
department such as radiology/laboratory and if the results
of the medical support examination have been obtained,
the patient must return to see the doctor. if during a
medical examination the doctor suggests that the patient
needs a consultation to another polyclinic / medical
rehabilitation, the patient is consulted to another polyclinic
by the doctor. and if during a medical examination the
doctor advises the patient to be hospitalized, the patient
is transferred from outpatient to inpatient registration.
After completing the medical examination, the patient is
given a prescription and goes to the drug service. after
completing the patient's drug service to the payment
counter to complete the entire administration of outpatient
services. Then the patient can go home. and if the patient
must be referred to another hospital, the doctor has
prepared a referral letter for the intended hospital
Penjelasan Alur Rawat Jalan
Pasien Datang kemudian menuju ke Tempat
Penerimaan Pasien Rawat Jalan, kemudian pasien
mendaftar sebagai pasien BPJS atau Umum di
Tempat Pendaftaran pasien Rawat jalan, kemudian
pasien menuju ke Poli Klinik yang dituju, setelah itu
pasien dipanggil untuk mendapatkan pemeriksaan
medis, jika pada saat diperiksa pasien membutuhkan
pemeriksaan penunjang medis maka pasien harus ke
bagian penunjang medis seperti
radiologi/laboratorium dan jika sudah mendapatkan
hasil pemeriksaan penunjang medis maka pasien
harus kembali lagi menemui Dokter. jika pada waktu
pemeriksaan medis dokter menyarankan pasien
membutuhkan konsultasi ke poli klinik lain /
rehabilitasi medis maka pasien dikonsulkan ke poli
klinik lain oleh Dokter. dan jika pada waktu
pemeriksaan medis dokter menyarankan pasien
untuk rawat inap maka pasien di pindah dari rawat
jalan ke pendaftaran pasien rawat inap. setelah
selesai pemeriksaan medis pasien diberikan resep
obat dan menuju ke pelayanan obat. setelah selesai
dari pelayanan obat pasien menuju keloket
pembayaran untuk menyelesaikan seluruh
administrasi pelayanan rawat jalan. kemudian pasien
bisa pulang. dan jika pasien harus di rujuk ke rumah
sakit lain, Dokter telah menyiapkan surat rujukan
untuk rumah sakit yang dituju.  
 MEDICAL RECORD FLOW FROM PATIENT ENTRY TO STORED MEDICAL RECORD
ALUR REKAM MEDIS DARI PASIEN MASUK SAMPAI REKAM MEDIS DISIMPAN
Patient register RM started
to be made
(Pasien mendaftar
RM mulai dibuat) Consultation data, surgery/anaesthesia,
Pathology data, X-ray (X-Ray), ECG physiotherapy
(Data patologi, Rontgen (X-Ray), EKG) Patients in the ward clinical data were (Data konsultasi, operasi/anaestesi, fisioterapi)
recorded in RM
(Pasien di bangsal data klinis dicatat
dalam RM)
The doctor completes the
RM assembled and final diagnosis/surgery,
analyzed for completeness summary and signature
Entry code data in
(RM diassembling dan (Dokter melengkapi
disease/surgery or procedure diagnosis akhir/operasi,
index dianalisis kelengkapannya)
Ringkasan Pulang (Resume)
Data kode dientry dalam dan tanda tangan)
indeks penyakit/operasi atau
prosedur RM is coded by RMIK Work Unit staff using ICD-10
(RM dikoding oleh staf Unit Kerja RMIK
menggunakan ICD-10)
Morbidity Complete Medical
Complete
Statistics Record
RM saved
(Statistik (Rekam Medis Lengkap)
(RM
Morbiditas)
lengkap
disimpan)
EXPLANATION OF MEDICAL RECORDS FROM PATIENT ENTRY TO STORED RM
PENJELASAN ALUR REKAM MEDIS DARI PASIEN MASUK SAMPAI REKAM MEDIS DISIMPAN

 The patient registers then the medical record officer prepares the medical record if
the patient has already registered, but if the patient is new then the medical record
is started.
Pasien mendaftar kemudian petugas rekam medis menyiapkan rekam medis jika pasien sudah pernah
mendaftar, tetapi jika pasien baru maka rekam medis mulai dibuat.

 Patients in the ward clinical data is recorded in the medical record, including
consultation data, surgery/anaesthesia, physiotherapy, pathology data, x-rays, ECG
are all recorded in the medical record.
Pasien di bangsal data klinis dicatat dalam rekam medis, termasuk data konsultasi, operasi/anaesthesi,
fisioterapi, data patologi, rontgen (x-ray), EKG dicatat semua dalam rekam medis.

 After the patient is declared to be allowed to go home, the medical record is

returned to the RMIK / MIK work unit
Setelah pasien dinyatakan boleh pulang, Rekam Medis dikembalikan ke unit kerja RMIK / MIK
 Then the medical record is assembled and analyzed for completeness, if yes,
the medical record is then coded by the RMIK Work Unit staff using ICD-10. but
if the medical record is incomplete, the doctor must complete the final
diagnosis/operation, a summary of discharge (resume) and signature, then after
it is complete it can only be coded by the medical record staff.
Kemudian rekam medis diassembling dan dianalisis kelengkapannya, jika ya rekam medis kemudian
dikoding oleh staf Unit Kerja RMIK menggunakan ICD-10. tetapi jika rekam medis tidak lengkap Dokter harus
melengkapi diagnosis akhir/operasi, ringkasan pulang (resume) dan tanda tangan, kemudian setelah lengkap
baru bisa dikoding oleh staf Rekam Medis.

 After the medical record is coded, the entry code

data is included in the disease/operation index or
procedure
Setelah rekam medis dikoding maka data kode dientry  Furthermore,
dalam indeks penyakit/operasi atau prosedur medical records
are processed to
make statistical
data on morbidity
After the medical record is complete then the medical in hospitals
record is stored in the medical record installation. Selanjutnya rekam
Setelah rekam medis lengkap barulah rekam medis disimpan di medis diolah untuk
instalasi rekam medis. dibuat data statistik
morbiditas di rumah
sakit
QUESTION

1) The definition of a medical record is...

a) report recording activities
b) hospital health implementation activities
c) a file that provides all aspects of health
d) Medical record is a file containing records and documents regarding patient
identity, examination, treatment, actions and other services that have been
provided to patients.

2) Protect the security of medical records to ensure confidentiality is mainted. is

the responbility of?
a) medical records technician
b) medical records staff
c) medical record
d) medical recods admission

3) The medical record section that functions to assemble the form is...
e) assembly
f) filing
g) coding/indexing
h) analysis/reporting
THANK YOU