CHARGING MEDICAL RECORD

Mr. B is 34 years old come to the Hospital Unimus. He was received by

dentists, then Mr. B conducted an exhaustive examination by the dentist to record
all inspection results. Grievances felt was pain on the tongue and gums near the
right and left cheek that stung the edges with a reddish color. She had been sick
and for a week he was led to a lack of sleep. As first aid, he was taking an oral
medication bought from a small shop next to his home. When the examination he
could not open his mouth, on the front teeth, it can be opened only in the width of
two fingers.

STEP 1

1. Medical record
Is a systematic and legal document regarding history of patients
by health care facility.

STEP 2

1. What the function medical record?

2. What medical record basic from the law?
3. What kind of medical record?
4. When medical record can be opened and who can open?
5. What the reason medical record can be change?
6. What should be fill in the medical record form?
7. What is the diagnosis in scenario?
8. When medical record expired?

STEP 3

1. What the function medical record?

- For decided diagnosis of patients, education, and experience.
- Responsibility doctor
- Can decided price of the financial
- To give information, and protecting the doctor and patients.
- Clinical source
- Can be giving information to other doctor
- Basic for treatments
2. What medical record basic from the law?
- UU 46 pasal 1 about medical practice, doctor or dentist must made a
medical record in the medical practice for data patients
- Permenkes No.269 th. 2008 about medical record
- Etc.
 3. What kind of medical record?
- Conventional medical record
Make from manual hand writing, using form from hospital or medical
practice.
- Electronic medical record
Make data using computer
4. When medical record can be opened and who can open?
- Can open by doctor, dentist, mid-wife, police or judge, family from
patients.
- When the doctor need information doing the treatment
- When medical practice need autopsy as a medical history care or
treatment receive diagnosis result and medication taken.

5. What the reason medical record can be change?

- Because has a multiple disease
- If found a false diagnosis, we should change the medical record to the new
one
6. What should be fill in the medical record form?
- No. medical record
- Doctor identity
- Patient identity(name, age, gender,etc.)
- Date and time(when the first, and last check)
- Medical history(can written by examination, diagnosis, and treatment)
- General examination
- Family history
- Dental record(odontogram)
- Prognosis
- Signature

7. What is the diagnosis in scenario?

- Trismus, he could not open his mouth, on the front teeth, it can be opened
only in the width of two fingers.

8. When medical record expired?

- After 5 years.(practice)
- After 10 years(hospital), if the patient control regularly isnt expired

When medical record expired, will be burn

STEP 4

STEP 5

1. What medical record basic from the law?

2. What kind of medical record?
3. What should be fill in the medical record form?
4. What is the diagnosis in scenario?
5. When medical record expired?
6. International classification of disease(ICD10)?