DAFTAR ISI

I. KATA PENGANTAR ....................................................................... i

II. DAFTAR ISI ....................................................................... ii

III. PENDAHULUAN ...................................................................... 1

IV. STRUKTUR ORGANISASI ..................................................................... 3

V. URAIAN TUGAS DAN TANGGUNG JAWAB ...................................... 4

VI. PROSEDUR TETAP PELAYANAN REKAM MEDIK .......................... 9

1. Penerimaan pasien lama rawat jalan ........................................................................9

2. Pendaftaran pasien rawat inap ................................................................................10
3. Penataan berkas rekam medic rawat jalan ...............................................................11
4. Penyimpanan berkas rekam medis ...........................................................................12
5. Penyusunan berkas rekam medis ................................................................. 13
6. Pengkodean penyakit ....................................................................................14
7. Pengkodean dan pengindeksan diagnose rawat jalan ..............................................15
8. Pengkodean dan pengideksan diagnose rawat inap ..................................................16
9. Peminjaman berkas rekam medis .............................................................................17
10. Penyusutan arsip rekam medis .................................................................................18
11. Pembuatan laporan kegiatan rumah sakit RL.1 ........................................................19
12. Pembuatan laporan individual rawat inap ................................................................20
13. Pemberian nomor rekam medic ................................................................................21
14. Kartu indeks utama pasien ( KIUP ) .......................................................................23
15. Penulisan nama baku pasien ....................................................................................24
16. Penyimpanan berkas rekam medic rawat inap .........................................................26

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17. Pemakaian symbol pada berkas rekam medic ..........................................................27
18. Pemberian kode penyakit ( Coding ) ........................................................................29
19. Penyediaan amplop berkas rekam medic rawat inap................................................31
20. Pengolahan berkas rekam medic rawat inap ............................................................32
21. Evaluasi pengelolaan rekam medic .........................................................................34
22. Pemberian indeks ....................................................................................35
23. Analisa kelengkapan berkas rekam medic rawat jalan ............................................36
24. Analisa kelengkapan berkas rekam medic rawat inap ..............................................37
25. Pengambilan kembali/ retrieval berkas rekam medic rawat inap .............................38
26. Pengambilan kembali/ retrieval berkas rekam medic rawat jalan ............................39
27. Kejadian / kasus luar biasa ( KLB ) ...................................................................... 40
28. Pengisian register pasien pulang opname ..................................................................41
29. Keamanan dan kerahasiaan rekam medic ...............................................................42
30. Penyerahan berkas rekam medic rawat inap ...........................................................43
31. Visum et repertum ....................................................................................44
32. Pelaporan ....................................................................................45
33. Penyusutan rekam medic in aktif .............................................................................46
34. Pemusnahan berkas rekam medic in aktif ...............................................................47
35. Pengisian formulir asuransi ....................................................................................49
36. Penerimaan pasien instalasi gawat darurat ...............................................................50
37. Penyimpanan berkas rekam medic rawat jalan ........................................................51
38. Identifikasi bayi baru lahir ....................................................................................52
39. Sensus harian pasien rawat inap ...............................................................................53
40. Pembuatan grafik Barber Jhonson ............................................................................54
41. Pengumpulan sensus harian rawat jalan ...................................................................55
42. Pemantauan rawatan ulang pasien rawat inap ..........................................................56
43. Pengadaaan dan pendistribusian barang ...................................................................57
44. Pengurusan legalisir surat kematian .........................................................................58
45. Informed Consent ( persetujuan tindakan medis )....................................................59
46. Surat keterangan opname ....................................................................................62
47. Surat keterangan sakit ....................................................................................63

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 48. Surat keterangan meninggal ....................................................................................64
49. Surat cuti hamil/ cuti melahirkan .............................................................................65
50. Penerimaan telepon masuk dan telepon keluar ( operator ) .....................................66
51. Penerimaan pasien baru rawat inap ..........................................................................67
52. Peminjaman berkas rekam medik eksternal .............................................................69

V. PENUTUP …………………………………………………………………….70

VI. LAMPIRAN
1. Surat pengajuan peminjaman berkas rekam medik kepada pihak kepolisian

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