DAFTAR ISI

Halaman Judul................................................................................................i
Surat Keputusan Direktur RS Nahdlatul Ulama Banyuwangi..................ii
Kata Pengantar...............................................................................................iii
Daftar Isi..........................................................................................................iv
BAB I. Pendahuluan.......................................................................................1
1.1. Latar Belakang..............................................................................1
1.2. Tujuan Pedoman...........................................................................2
1.3. Ruang Lingkup Pelayanan............................................................2
1.3.1. Pengertian Rekam Medis....................................................2
1.3.2 Kegunaan Rekam Medis......................................................3
1.3.3. Sifat Rekam Medis..............................................................4
1.3.4. Tujuan Rekam Medis..........................................................4
1.3.5.Isi Rekam Medis..................................................................5
1.4. Batasan Operasioanal...................................................................7
1.5. Landasan Hukum...........................................................................8

BAB II. Standar Ketenagaan.........................................................................10

2.1. Kualifikasi Sumber Daya Manusia...............................................10
2.2. Pengaturan Shift...........................................................................12

BAB III. Standar Fasilitas.............................................................................13

3.1. Denah Ruang Instalasi Rekam Medis...........................................13
3.2. Standar Fasilitas............................................................................14

BAB IV. Tata Laksana Pelayanan.................................................................17

4.1. Penerimaan Pasien........................................................................17
4.2. Pelayanan Pendaftaran Rawat Jalan.............................................18
4.2.1. Pasien Baru.........................................................................18
4.2.2. Pasien Lama........................................................................19
4.2.3. Alur Pendaftaran Pasien Rawat Jalan Poliklinik.................20
4.3. Pelayanan Pendaftaran Rawat Inap..............................................20
4.3.1. Alur Pendaftaran Pasien Rawat Inap Poliklinik..................24

iv
 4.3.2. Pelayanan Pendaftaran Pasien Gawat Darurat....................24
4.3.3. Alur Pendaftaran Pasien Gawat Darurat.............................26
4.4. Sistem Penomoran dan Identifikasi..............................................27
4.4.1. Pemberian Nomor Rekam Medis........................................27
4.4.2. Pemberian Identitas Pasien Umum.....................................29
4.4.3. Pemberian Identitas Bayi Baru Lahir..................................31
4.4.4. Pemberian Identitas dan Penomoran Pasien di Instalasi
Gawat Darurat....................................................................32
4.4.5. Penulisan Nama...................................................................33
4.5. Pengolahan Analisa Data dan Pelaporan......................................36
4.5.1. Alur Rekam Medis Rawat Jalan..........................................37
4.5.2. Alur Rekam Medis Rawat Inap...........................................39
4.5.3. Assembling dan Analisis.....................................................41
4.5.4. Koding.................................................................................43
4.5.5. Indeksing.............................................................................43
4.5.6. Pelaporan Rekam Medis.....................................................46
4.6. Simbol, Tanda Khusus dan Singkatan..........................................46
4.6.1. Daftar yang tidak boleh di singkat......................................52
4.7. Pencatatan dan Pengisian Rekam Medis......................................57
4.7.1. Pencatatan Rekam Medis....................................................57
4.7.2. Pengisian Rekam Medis......................................................67
4.7.3. Informed Consent................................................................72
4.7.4. Surat Keterangan Medis......................................................76
4.7.5. Penulisan Diagnosis............................................................80
4.8. Peminjaman dan Pemeliharaan Berkas Rekam Medis..................81
4.8.1. Peminjaman Berkas Rekam Medis.....................................81
4.8.2. Pemasangan Lembar Perunut Tracer/Out Guide dan
Pengambilan Berkas Rekam Medis....................................91
4.8.3. Pendistribusian Berkas Rekam Medis.................................92
4.8.4. Pengembalian Berkas Rekam Medis...................................93
4.9. Pengamanan Kerahasiaan dan Pemeliharaan Rekam Medis.........96

v
 4.10. Pelepasan Informasi.....................................................................98
4.11. Penyimpanan Rekam Medis........................................................101
4.11.1. Sistem Penyimpanan.........................................................101
4.11.2. Sistem Penjajaran..............................................................102
4.11.3. Penomoran.........................................................................104
4.11.4. Ketentuan dalam Penyimpanan Berkas Rekam Medis.....105
4.12. Pemisahan dan Pemusnahan Rekam Medis In-Aktif..................106
4.12.1. Pemisahan Berkas Rekam Medis In-Aktif........................106
4.12.2. Pemusnahan Berkas Rekam Medis In-Aktif.....................110
4.12.3. Penyimpanan, Retensi dan Pemisahan Arsip RM.............111
4.12.4. Pelaksanaan Penyimpanan dan Pemusnahan Arsip di
RS Nahdlatul Ulama Banyuwangi....................................125

BAB V. Logistik...............................................................................................134

BAB VI. Keselamatan Kerja.........................................................................136

BAB VII. Pengendali Mutu ...........................................................................139

BAB VIII. Penutup.........................................................................................151

v
vi