DISUSUN OLEH :
FRETIA ARINI
18D30455
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Table Of Contents
Chapter I ......................................................................................................................... 4
PRELIMINARY ............................................................................................................. 4
A. BACKGROUND ................................................................................................ 4
B. TEST ................................................................................................................... 4
Chapter II ........................................................................................................................ 5
Definition of Medical Records........................................................................................ 5
1. Definition of Medical Records ............................................................................ 5
Chapter III ....................................................................................................................... 7
Medical Record Objectives ............................................................................................. 7
2. Medical Record Objectives ................................................................................. 7
Chapter IV ....................................................................................................................... 9
Medical Record Function ................................................................................................ 9
3. Medical Record Function .................................................................................... 9
Chapter V ...................................................................................................................... 10
Benefits of Medical Records ......................................................................................... 10
4. Benefits of Medical Records ............................................................................. 10
Filling ........................................................................................................... 11
Chapter VI..................................................................................................................... 12
Basic Elements of Management in Medical Records ................................................... 12
5. Basic Elements of Management in Medical Records ....................................... 12
Chapter VII ................................................................................................................... 13
Equipment used............................................................................................................. 13
6. Equipment used ................................................................................................. 13
Tracer ........................................................................................................... 23
Color Code ................................................................................................... 23
ChapterVIII ................................................................................................................... 25
Duties and Responsibilities Of Medical Recorders ...................................................... 25
7. Duties and Responsibilities Of Medical Recorders .......................................... 25
Chapter VIIII ................................................................................................................. 30
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MEDICAL RECORD AMOUNT AND CREDIT NUMBERS based on
PERMENPAN-RB 30/2013.......................................................................................... 30
8. MEDICAL RECORD AMOUNT AND CREDIT NUMBERS based on
PERMENPAN-RB 30/2013...................................................................................... 30
Reference ...................................................................................................................... 33
Signature Form.............................................................................................................. 34
iii
Chapter I
PRELIMINARY
A. BACKGROUND
Medical record is one of the written proofs about the process of
service provided by doctors and dentists. In the medical record contains
the patient's clinical data during the process of diagnosis and treatment
(treatment). Therefore every medical service activity must have a
complete and accurate medical record for each patient and every doctor
and dentist must fill in the medical record correctly, completely and on
time.
Theoretically, medical records can be interpreted as "information
both written and recorded about identity, history, determination of
physical laboratories, diagnosis of all services and medical actions given
to patients, including treatment, whether undergoing outpatient care,
hospitalization, or inpatient care. emergency ".
Thus a patient's medical record must contain all information about
the patient's health status, where this can be used as a basis in determining
further actions in service efforts and other medical actions in these
patients in health care facilities
B. TEST
Knowing the Role,Function,definition etc of Medical Record Medical
Services and Health Information in Medical Record Services (RM)
4
Chapter II
Definition of Medical Records
5
services they obtain and contain enough information to identify (identify)
patients, justifying diagnosis and treatment and record the results.
6
Chapter III
Medical Record Objectives
7
g. Documentation aspects. A medical record file has documentation
value, because the contents are related to the source of memory that
must be documented and used as material for accountability and health
service facility reports.
8
Chapter IV
Medical Record Function
9
Chapter V
Benefits of Medical Records
10
Filling
1. Definition
Filing in the field of medical records is a room that is responsible for
the storage, retention and destruction of medical record documents. In
addition filing also provides medical record documents that have
complete contents so that it can facilitate the use of searching information
at any time if needed.
2. Main Duty
a. Save DRM with certain methods according to
DRM retention policy,
b. Retrieving DRM for various purposes,
c. Depreciate (retention) DRM in accordance with the provisions
stipulated health service facilities,
d. Separating inactive DRM storage from active DRM,
e. Helps in value assessment for medical records,
f. Storing preserved DRM (perpetuated), and
g. Assisting in the destruction of medical record forms.
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Chapter VI
Basic Elements of Management in Medical Records
12
Chapter VII
Equipment used
6. Equipment used
• Storage Media:
1) Cabinet Filing
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the placement and rediscovery of the archive does not consume much
energy. This tool is made of strong materials such as metal or iron.
Archives are stored later on this device.
3) Filing Cabinets
Is a cabinet where files are stored in various forms of
archives. This cabinet can be made of wood or iron which is equipped
with doors that use hinges, push doors, or even use glass. There are
also those that are made to store lots of files by saving space, cabinets
like this are called roll o packs. Arrangement of archives can be done
by standing sideways (lateral) with the first file entered into ordner or
by stacking horizontally (horizontally) with the first file entered into
the folder, serves to store various forms of archives.
3) Archive shelves
14
4) Card Rack / Drawer
15
7) Box / Box
Is a box that is used to store records that are inactive.
Usually made of thick cardboard. The files stored in the box are first
saved into a folder. Next this box will be placed on the archive shelf
(lateral to the side).
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Computers are machines that process facts or data into
information. Computers are used to improve work results and solve
various problems. And can save and display information needed.
10) Lighting
Lighting is the amount of irradiation in a field of work
needed to carry out activities effectively. Good lighting can provide
advantages, namely:
1) Improvement of services
2) Increased accuracy
3) Better health
4) A more comfortable working atmosphere
5) Better work safety.
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(4) No KIUP is needed.
c) Losses
(1) The patient's medical information becomes unsustainable.
(2) Storage space becomes full quickly.
2) Unit Number Numbering
A.1) Definition
Provision of medical record number by unit or unit
numbering system (UNS) is a system of providing medical record
numbers for patients who come for treatment for the first time and
the number is still used at the time of the next visit.
B.1) Benefits
(1) Patient medical information can be continuous.
C.1) Losses
(1) Service for old patients requires a longer time because the staff
must look for medical record documents on behalf of the patient
first.
(2) Patients who do not bring KIB for longer periods of service.
(3) Unit Series Numbering
A.2) Definition
Provision of serial unit numbering system (SUNS) is a
system for administering medical record numbers by combining
serial and unit systems. Every patient who comes for treatment will
get a new medical record number with a new document as well.
Then after completion of the service, the medical record number on
the medical record document is sought at KIUP to ensure the patient
has visited or not. If the patient is old, the new and old medical
record documents will be put together. And stored based on the old
medical record number.
B.1) Benefits
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(1) Services are faster because they are not
distinguish between old patients and new patients.
C.1) Losses
(1) Officer workload increases because after services must
incorporate old and new medical record documents.
(2) Medical information is not sustainable at the time of service, but
will be continuous in subsequent services.
b. Storage System
(1) Centralization
a) Definition
A storage system by uniting medical record forms (outpatient,
hospitalization,
emergency) a patient into a folder.
b) Benefits
(1) Medical information of a patient can be continuous.
(2) Duplication in the maintenance and storage of medical records
can be avoided.
c) Losses
(1) Filing room must be open for 24 hours.
(2) Decentralization
a) Definition
A storage system by separating a patient's medical record forms,
outpatient and emergency care forms is put together, while inpatient
forms are kept separate.
b) Benefits
(1) The workload of officers is lighter because it only handles
outpatient and emergency care documents, or just hospitalizations.
(2) Service time efficiency.
c) Losses
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(1) Duplication occurs in making medical records.
(2) Requires more costs because it requires more storage space.
d.) Alignment System
3) Direct Number Method
a) Definition
Alignment with direct number systems or often called straight
numberic filling (SNF). That is how to store sequential medical
record documents in accordance with the order of medical record
numbers. For example, the following four medical record numbers
will be stored in one rack in a row: 46-50-23, 46-50-24, 46-50-25,
46-50-26.
b) Benefits
(1) Easy to train officers to work in this section.
(2) If you will take 50 pieces of medical records at the same time
sequentially for the sake of research or retention, it is easy to do.
c) Losses
(1) The officer must remember the six digit numbers at once.
(2) Easy to get misplaced. For example in numbers
medical record 46-54-26 can be considered 46-45-26 by the officer.
(3) Archiving activities will be concentrated on the shelf
storage with large numbers or the latest medical record number, so
that some officers will jostle in the same area.
(4) Quality control of filing or tidiness monitoring is difficult
because it is not easy to give an officer an area of responsibility.
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The alignment system with the final digit method (TDF) is a
system of storing medical record documents by aligning the medical
record document folder based on the sequence of medical record
numbers in the 2 final group numbers. Example
Section 02 Section 26 Section 30 Section 31
46-52-02 98-05-26 98-99-30 00-00-31
47-52-02 99-05-26 99-99-30 01-00-31
48-52-02 00-06-26 49-52-02 01-06-26
b) Benefits
(1) The addition of the number of medical record documents is
always spread evenly on 100 groups (sections) in the storage rack.
(2) Officers do not jostle in the same storage area.
(3) Officers can be given responsibility for certain sections. For
example: section 00-24, section 25.49, section 50-74, section 75-99.
(4) The number of medical record documents in each section can be
controlled and can avoid the emergence of empty shelves.
(5) With the control of the number of medical records, help
make it easy to plan storage (number of shelves).
(6) Inactive medical record documents can be taken from the
storage rack in each section when a new medical record is added.
(7) Laying errors (missfile) can be prevented, because
officers only pay attention to a pair of numbers.
(8) Color code can be applied.
c) Losses
(1) Training and guidance will take time
longer than training using the direct number system, but generally
officers can be trained in a not too long time.
(2) Requires a large initial cost because it must
prepare 100 racks first.
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5) Middle Number Method
a) Definition
The alignment system with the middle digit filling method
(MDF) is a system of storing medical record documents by aligning
document folders based on the sequence of medical record numbers in
2 numbers in the middle group. Example:
56-78-96 99-78-96
56-78-97 99-78-97
56-78-98 99-78-98
56-78-99 99-78-99
57-78-00 00-79-00
57-78-01 00-79-01
b) Advantage
(1) 100 of the first medical record documents are always located
in 1 group (section) inside the storage rack.
(2) Officers do not jostle in one place
same storage.
(3) Officers can be given responsibility for a number
certain section. For example: section 00-24, section 25
49, section 50-74, section 75-99.
(4) Number of medical record documents in each section
can be controlled and can avoid the emergence of empty shelves.
(5) With the control of the number of medical records, it helps
facilitate the planning of the storage area (number of shelves).
(6) Inactive medical record documents can be taken from the
storage rack in each section when a new medical record is added.
(7) Laying errors (missfile) can be prevented, because officers only
pay attention to a pair of numbers.
(8) Color code can be applied.
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c) Losses
(1) Training and guidance will take longer than training using the
direct number system, but generally officers can be trained in the
not too distant future.
(2) Require a large initial cost because they have to prepare 100
shelves first. In addition to the above systems, there are other ways
that are applied in the filing room in order to prevent missfile
documents, namely:
Tracer
a) Definition
Tracer is a card that is used as a guide for the use or issuance
of a medical record document from a filing rack so that it can be used
to borrow medical record documents into filing. This card serves as a
substitute for medical record documents taken. Tracer contains the
medical record number, name, loan date, borrower's name, purpose of
using the loan.
Color Code
a) Definition
Color code is the use of colors in the medical record folder
to help prevent the occurrence of missfiles and facilitate the search for
misplaced documents (missfile). This color is located on the edge of
the folder. This method is most effective when applied to a final
number storage system or a middle number storage system, although it
can also be applied to direct number storage systems Color code
settings
Two digit primary number One digit primary number Color
00 - 09 0 Purple = purple
10-19 1 Yellow = yellow
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20 - 29 2 Dark green = dark green
30 - 39 3 Orange = orange
40 - 49 4 Light blue = light blue
50 - 59 5 Brown = brown
60 - 69 6 Cerise = reddish
79 - 79 7 Light green = light green
80 - 89 8 Red = red
90 - 99 9 Dark blue = dark blue
6. Market or marketing
is an activity where the organization disseminates (markets)
its products (goods / services). Medical records play a role in
marketing hospitals through services provided to patients.
7. Quality of Service
In general, the notion of service quality is the degree of
service perfection that conforms to professional standards and service
standards by using the potential of available human resources in a
reasonable, effective, and efficient manner and given safely and
satisfactorily in accordance with norms, ethics, law, and social culture
by paying attention limitations and abilities possessed. In managing
filing, service quality can be said to be good if the missfile does not
occur or the required medical record documents can be found all
quickly and accurately.
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ChapterVIII
Duties and Responsibilities Of Medical Recorders
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3. carry out the clinical classification system and codification of
diseases related to health and medical actions according to the correct
medical terminology;
4. carry out the index by collecting data on diseases, deaths, actions
and doctors grouped in the index;
5. implement a reporting system in the form of information on health
service activities;
6. designing the structure of the contents and standards of health data,
for the management of health information;
7. carry out a complete evaluation of the contents of the diagnosis and
action as the accuracy of the coding;
8. carry out data collection, validation and verification according to
hospital statistics;
9. recording and reporting of surveillance data;
10. manage work groups and management of work units and run
organizing organizations and health service providers;
11. socialize each medical record service program and health
information;
12. carry out work relations in accordance with the professional code
of ethics; and
13. do self development towards the advancement of science and
technology.
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2. designing a manual and electronic medical record content evaluation
system;
3. designing the structure of the contents and standards of health data,
for the development of health information;
4. validate the completeness of the diagnosis and medical action as the
accuracy of the coding;
5. validate the index by assessing the data sets of diseases, deaths,
actions and doctors grouped in the index;
6. validate the collection and verification of data in accordance with
the type of survey form;
7. evaluating the clinical classification system and coding of diseases
related to health and medical actions in health financing;
8. report the results of monitoring the performance of the quality of
medical record services and health information relating to science and
technology;
9. analyze and evaluate the management of work unit management and
run the organization of health service facilities;
10. resolve procedural problems both manually / electronically; and
11. carry out work relations in accordance with the professional code
of ethics.
27
4. draft alternative health management information solutions using the
principles of the medical record system and health information / Health
Information Management;
5. creating a new design (innovation) alternative health information
management solutions using the principles of the medical record
system and health information / Health Information Management;
6. supervise the management of health information using the principles
of the medical record system and health information / Health
Information Management;
7. design and develop the structure of the contents and standards of
health data, for the development of health information;
8. validate the completeness of the diagnosis and medical action as the
accuracy of the coding;
9. validate the index by assessing the data sets of diseases, deaths,
actions and doctors grouped on the index
10. validate the collection and verification of data in accordance with
the type of survey form;
11. evaluating the clinical classification system and coding of diseases
related to health and medical actions;
12. communicate the partnership partnership of researchers in the field
of health information management using the principles of the medical
record system and health information / Health Information
Management;
13. do data analysis using science and technology;
14. contributing to research activities in the field of medical record
services and health information; and
15. carry out work relations in accordance with the professional code
of ethics
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in carrying out the work of medical records and health
information in the Health Service Facility, has the following
authorities:
1. develop electronic medical record design according to the service
system requirements and reporting using biostatistics;
2. develop specific designs according to the needs of developing
research modules together with other professional groups
3. develop the ability to analyze disease trends and distribute according
to the authorization of access and data security;
4. develop cooperation with epidemiology teams in designing disease
survey designs as well as population demographics;
5. developing a website / site-based public health information system
6. develop an electronic medical record service evaluation system
published.
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Chapter VIIII
MEDICAL RECORD AMOUNT AND CREDIT NUMBERS based
on PERMENPAN-RB 30/2013
30
• Civil Servants who are appointed for the first time in functional
positions of the skilled Medical Recorder must fulfill the following
requirements:
A. The lowest diploma Diploma III (D.III) medical record
health information
B. The lowest rank of the Regulator, the space group II / c;
C. Has a Regristation Sign (STR) Medical Recorder that is still
valid
D. The work performance value is at least worth good in the
last 1 (one) year
• Civil Servants appointed for the first time in functional positions
Medical Records Experts must meet the following requirements:
A. The lowest diploma is Bachelor (S.1) / Diploma IV (D.IV)
medical record
B. Has a Regristation Sign (STR) Medical Recorder that is still
valid
C. The lowest rank of the young stylist, class room III
D. The work performance value is at least worth good in the
last 1 (one) year
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E. Amount of payment reimbursement claims;
F. Working hours of medical record services and 24-hour health
information
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Reference
https://sainsmini.blogspot.com/2015/08/rekam-medis-pengertian-tujuan-fungsi.html
http://yanlaitabun.blogspot.com/2015/02/belajar-ilmu-rekam-medis-dan-
kesehatan.html
file:///C:/Users/USER/Downloads/Documents/bab2_18513_2.pdf
http://rekammedissanglah.blogspot.com/2016/03/angka-kredit-dan-jumlah-tenaga-
rekam.html
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Signature Form
SCORE SIGNATURE
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