DAFTAR ISI

Halaman Judul .............................................................................................. 1

BAB I PENDAHULUAN ................................................................................. 2
A. Latar Belakang ................................................................................ 2
B. Ruang Lingkup ................................................................................ 2
1. Falsafah Rekam Medis ............................................................... 2
2. Pengertian Rekam Medis............................................................ 3
3. Tujuan Rekam Medis .................................................................. 4
4. Kegunaan Rekam Medis ............................................................ 4
C. Batasan Operasional ....................................................................... 6
D. Landasan Hukum ............................................................................ 7
1. Aspek Persyaratan Hukum ......................................................... 13
2. Pemilikan Rekam Medis ............................................................. 15
3. Kerahasiaan Rekam Medis ......................................................... 16
4. Persetujuan Tindakan Medis (Informed Consent) ....................... 18
5. Pemberian Informasi kepada Orang/Badan yang mendapat kuasa 21
6. Rekam Medis di Pengadilan ....................................................... 23
BAB II STANDAR KETENAGAAN ................................................................ 26
1. Kualifikasi Sumber Daya Manusia ................................................... 26
2. Distribusi Keterangan ...................................................................... 26
BAB III STANDAR FASILITAS ...................................................................... 28
A. Denah Ruang Instalasi Rekam Medis ............................................. 28
B. Standar Fasilitas Instalasi Rekam Medis ......................................... 29
BAB IV TATA LAKSANA PELAYAN AN........................................................ 30
A. Pelayanan Pendaftaran Rawat Jalan .............................................. 30
a. Pasien Baru ................................................................................ 30
b. Pasien Lama............................................................................... 31
c. Pasien Gawat Darurat ................................................................ 32
B. ADMISI atau Pelayanan Pendaftaran Pasien Rawat Inap ............... 33
1. Alur Penderita Rawat Inap ........................................................ 34

C. Sistem Identifikasi dan Penomoran ................................................. 34

1. Sitem Penamaan ...................................................................... 34
2. Sistem Penomoran ................................................................... 35
D. Klasifikasi Penyakit ......................................................................... 36
E. Pengelola dan Analisa Data ............................................................ 37
F. Simbol dan Tanda Khusus .............................................................. 43
G. Penyelesaian dan Pengemballian Rekam Medis ............................. 44
H. Penyimpanan Rekam Medis............................................................ 44
I. Pelepasan Informasi ....................................................................... 47
 J. Peminjaman Rekam Medik ............................................................. 50
K. Pemisah Rekam Medik In Aktif ........................................................ 52
L. Penghapusan Rekam Medis ........................................................... 53
BAB V LOGISTIK.......................................................................................... 55
BAB VI KESELAMATAN KERJA .................................................................. 58
BAB VII PENGENDALIAN MUTU ................................................................. 60
BAB X PENUTUP ......................................................................................... 66
DAFTAR PUSTAKA ...................................................................................... 67