DAFTAR ISI

Halaman Judul .............................................................................................................................................. i

Daftar isi ........................................................................................................................................................ ii
BAB I. PENDAHULUAN ................................................................................................................................. 1
1.1. Latar Belakang Rekam Medis ................................................................................................. 1
1.2. Ruang Lingkup ........................................................................................................................ 3
1.3. Falsafah Rekam Medis ............................................................................................................ 3
1.4. Pengertian Rekam Medis ....................................................................................................... 3
1.5. Tujuan Rekam Medis ............................................................................................................... 4
1.6. Kegunaan Rekam Medis ........................................................................................................ 4
1.7. Batasan Operasional ........................................................................................................................ 5
1.7.1. Managemen Rekam medis .............................................................................................................. 5
1.7.2. Rekam Medis ................................................................................................................................... 5
1.7.3. Admission ........................................................................................................................................ 5
1.7.4. Registrasi ......................................................................................................................................... 5
1.7.5. Tracer .............................................................................................................................................. 5
1.7.6. ICD X ................................................................................................................................................ 5
1.7.7. Kartu Berobat ................................................................................................................................ 5
1.7.8. Landasan Hukum ............................................................................................................................. 5
1.7.9. Aspek Persyaratan Hukum .............................................................................................................. 6
1.8. Pemilikan Rekam Medis .................................................................................................................. 7
1.9. Kerahasiaan Rekam Medis .............................................................................................................. 8
1.10. Persetujuan Tindakan Medis (Informed Consent) .......................................................................... 9
1.11. Pemberian Informasi kepada Orang/Badan Yang Mendapat Kuasa 26 ………………………………………… 10
1.12. Rekam Medis Di Pengadilan ............................................................................................................ 12
BAB II. STANDAR KETENAGAAN ................................................................................................................... 14
2.1. Kualifikasi Sumber Daya Manusia .......................................................................................... 14
2.2. Distribusi Ketenagaan ............................................................................................................. 14
BAB III. STANDAR FASILITAS ......................................................................................................................... 18
3.1. Denah Ruang Instalasi Rekam Medis ..................................................................................... 18
3.2. Standar Fasilitas Instalasi Rekam Medis ................................................................................. 20
BAB IV. TATA LAKSANA PELAYANAN ............................................................................................................ 21
4.1. Pelayanan Pendaftaran Rawat Jalan ......................................................................................... 21
4.2. Pelayanan Pendaftaran Rawat Inap .......................................................................................... 22
4.3. Sistem Identifikasi Dan Penomoran .......................................................................................... 24
4.4. Simbol dan Tanda Khusus ......................................................................................................... 25
4.5. Penyelesaian Dan Pengembalian Rekam Medis ....................................................................... 25
4.6. Penghapusan Rekam Medis ...................................................................................................... 28
4.7. Perekam Kegiatan Pelayanan Medis ……………………………………………………………………………………... 29
BAB V. LOGISTIK ...................................................................................................................................... 43
BAB VI. KESELAMATAN PASIEN ................................................................................................................ 44
BAB VII. KESELAMATAN KERJA ................................................................................................................. 46
BAB VIII. PENGENDALIAN MUTU .............................................................................................................. 47
6.1. Definisi Indikator ................................................................................................................... 47
6.2. Indikator Dan Standar Pelayanan .......................................................................................... 48
6.3. Uraian Standar Pelayanan Minimal ...................................................................................... 48
BAB IX. PENUTUP ..................................................................................................................................... 51
DAFTAR PUSTAKA ……………………………………………………………………………………………………………………………………. 52