RUMAH SAKIT UMUM SYLVANI Melayani Penuh Kasih Sayang KEPUTUSAN DIREKTUR RUMAH SAKIT SYLVANI BINJAL NOMOR : 1110/SK/DIR/IIL/2018 TENTANG STANDARISASI KODE DIAGNOSA, KODE TINDAKAN, DEFINISI, SIMBOL, DAN SINGKATAN DI RUMAH SAKIT SYLVANI BINJAL Mengingat » DIREKTUR RUMAH SAKIT SYLVANI BINJAL Bahwa dalam rangka keseragaman upaya peningkatan mutu pelayanan dan optimalisasi operasional Sistem Informasi Manajemen Rumah Sakit (SIM RS) dan pencatatan di rekam medik, maka diperlukan standarisasi kode diagnosa,kode prodesur/ tindakan,simbol,singkatan dan definisi Rumah Sakit Sylvani Binjai. Bahwa sehubungan dengan hal tersebut di atas perlu ditetapkan Standarisasi Kode diagnose, Kode prosedur / Tindakan, Simbol, Singkatan dan Definisi dengan Keputusan Direktur Rumah Sakit Sylvani Undang-Undang RI No.36 Tahun 2009 tentang Kesehatan; Undang-undang RI No.4 Tahun 2009 tentang Rumah Sakit: Peraturan Menteri Kesehatan Nomor 269 / Menkes / Per / III / 2008 tentang Rekam Medis Petunjuk Pelaksanaan Keputusan Direktur Kesehatan Angkatan Darat ‘Nomor : Kep/608/X11/2011 tanggal 27 Desember 2011 tentang pengesahan berlakunya Buku Pedoman tentang Sistem Pelaporan Teknis Medis di Lingkungan Kesehatan Angkatan Darat Peraturan Menteri Kesehatan Republik Indonesia Nomor 27 tahun 2014 tentang Petunjuk Teknis Sistem Indonesian Case Base Groups ( Ina ~cbgs).Menetapkan : KESATU KEDUA. KETIGA MEMUTUSKAN KEPUTUSAN DIREKTUR TENTANG STANDARISASI KODE DIAGNOSA, KODE TINDAKAN, DEFINISI, SIMBOL, DAN SINGKATAN DI RUMAH SAKIT SYLVANI BINJAI (Terlampir); Pemberlakuan Pengkodean Diagnosa Penyakit Penderita Menggunakan Standar resmi WHO dalam pengkodean Diagnosis International Statistical Classification of Diseases and Related Health Problems ( ICD-10) Revisi ke-10, Volume 1, 2 dan 3 tahun 1994.dan pengkodean prosedur / tindakan Keputusan ini berlaku sejak tanggal ditetapkan dengan ketentuan bilamana dikemudian hari terdapat kekeliruan dalam penetapannya akan diadakan perbaikan sebagaimana mestinya, Ditetapkan di: Binjai Padatanggal —: 12 Maret 2018 Direktur Rumah Sakit Sylvani Binjai dr. Dovi Camela Sitepu, M.KesLampiran Keputusan Direktur Rumah Sakit Sylvani Binjai Nomor 1110/SK/DIRMIL2018 Tanggal 12 Maret 2018 DAFTAR STANDARISASI KODE DIAGNOSA, KODE TINDAKAN, DEFINISI, SIMBOL, DAN SINGKATAN DI RUMAH SAKIT SYLVANI BINJAL KOMPILASI DAFTAR SINGKATAN DIAGNOSIS DAN TINDAKAN NO | SINGKATAN KEPANJANGAN KET 1 [AB ‘Asthma Bronchiale - | 2 | ABC Airway, Breathing, Circulation | 3_| ABP PAtigis Biase Pints RuBe Meanie tNtll Menu tie entennt||E 4 [ABVD Andriomycin, Bleomyein, Vinblastin, Dacarbazine [5 | ACL ‘Anterior Cruciate Ligament 6 | AIHA ‘Auto Immune Hemolytic Anemia 7 [Al ‘Angkat Jahitan (Luka) 8 | ALL ‘Acute Lymphoblatic Leukemia 9 |ALs ‘Amyotrophic Lateral Sclerosis 10 | AML ‘Acute Myeloid Leukemia 11_| AMP Austin Moore Prothesis 12 | AP ‘Antero — Posterior [cea 13 | ARDS Acute Respiratory Distress Syndrome 15 | ATN ___| Acute Tubular Necrosis - 16 | AV Shunt Arterio Venous Shunt 17 | AVN | Arteri, Vein, Nerve 18 | BAB/K Buang Air Besar / Kecil - 19 | BBB Batu Buli-Buli TL ] 20 | BCC Basal Cell Carcinoma 21 | BCT/S Breast Concerving Treatment / Surgery a 2 | BK Bronchitis Kronis 23 | BNI \dder Neck Incision - | 24 | BP mchopneumonia | 25 BP Bell's Palsy - | 26 | BPH Benign Prostate Hyperplasia 27 | BSK. | Batu Saluran Kencing 28 | BTA Basil Tahan Asam 29 [Ca Carcinoma 30 | Ca Calcium | 32_| CAF Cyclophosphamide, Adriamycin, Fluorouracil [33 | CAH Chronic Active Hepatitis 34 [CF Closed Fracture 35_| CHBV Chronis Hepatitis B Virus 36 Chronic Kidney Disease td37 | CLL Chronic Lymphocytic Leukemia 38 | CML. Chronic Myeloid Leukemia 39 | COB Cidera Otak Berat 40 [COR Cidera Otak Ringan 41_| COS Cidera Otak Sedang i 42 | CRS Cervical Root Syndrome | | 43 | CT Scan ‘Computed Tomography Sean | 44 | CTEV ‘Congenital Talipes Equino Varus | 45 [CVA Cerebro Vascular Accident 46 | CVD Cerebro Vascular Diseases 47 | cvP Central Venous Pressure 48 | DCS Damage Control Surgery 49 | DHF Dengue Hemorrhagic Fever 50 | DHS. Dynamic Hip Screw si | DIC Disseminated Intravascullar Coagulation $2 | DI Stent Double J Stent | 53_| DKD Diabetic Kidney Disease 54 | DL. Darah Lengkap 55_|DM Diabetes Mellitus | 57_| DMP. Dystrophia Musculorum Progressiva | 38 | DPL Diagnostik Peritoneal Lavage | 59 | DSS Dengue Shock Syndrome | 60 | DVT Deep Vein Thromboses | 61 | EDH Epidural Hematome | 62_| EEG Electro Encephalography 63_| EKGIECG Elektro Cardiography 64 | ET Endotracheal Tube 65 | EVD Extra Ventricular Drainage 66 | FUO Febris of Unknown Origin 7 | 67 | GEA Gastro Enteritis Acuta 68 | GEDS Gastro Enteritis Dehidrasi Sedang 69 [GGA Gagal Ginjal Akut 70 | GGK | Gagal Ginjal Kronis _ | 71 | Gor Gagal Ginjal Terminal 72 | GNA Glomerulonephritis Acuta 73 | GNC Glomerulonephritis Chronica “74 [HM Hematemesis Melena - 75 | HT Hipertensi 76 | IDDM/DM1I__| Insulin Dependent Diabetes Mellitus / DM type 1 77 [ISK Infeksi Saluran Keneing 78 |iTP Idiopathic Thrombocytopenia Purpura | 79 |KAD Ketoacidosis Diabeticum | 80 | KP Koch Pulmonumsi_| MM Multiple Myeloma 82 | MOF __| Multo Organ Failure 83 [ND Nephropatia Diabetica 84 | NGT ‘Naso Gastric Tube 85 ORM DM Non Insulin Dependent Diabetes Mellitus / DM type 2 | 86 [NS Nefiotie Syndrome 1 87 [OA Osteoarhtrosis 88 | PPOM Penyakit Paru Obtruktif menahun 89 [RA Rheumatoid Arthritis { 90 _| RF Rheumatic Fever I o1 | SH Sirosis Hepatitis | 92 | SLE Systemic Lupus Erythematosus { 93 | TB ‘Tuberkulosis | 94 | Tu Tumor I 95 | URL Upper Respiratory Infection I 96 | WSD Water Sealed Drainage 97 | FAM. Fibroadenoma Mamma 98 | FCD Fibrocystic Disease 99 | FL Faeces Lengkap 100 | FNAB Fine Needle Aspiration Biops; 101 | Fr Fraktur 102 | SFU 5 Fluorouracil 103 | GA General Anaesthesia z I 104 | GCs Glasgow, Coma, Scale 105 | HD Hodgkin Disease 106 | HE/HI __| Hemorrhoid Eksterna / Intema 107 | HIL DiS. Hemia Inguinalis Lateralis Dextra / Sinistra, 108 | HIM D/S. Hemia Inguilanis Medial Dextra / Sinistra | 109 | HNP ‘Hemia Nucleus Pulposus I 110 | IBD Inflamatory Bowel Disease | 11 | 1CD-9CM International Classification of Diseases 9th revision Clinical Modification | 112} ICD-10 International Statistical Classification of Disease and ] Related Health Problems, 10 th Revision 113 |1&D Incisi Drainage 114 | ICH Intracerebral Hemorrhage [ 115 | Ics. | Intercostal Space _ - ie 116 | CU Intensive Care Unit 117 | 1O1D Wiring | Inter Osseus Inter Dental Wiring | 118 | IVP Intravenous Pyelography 119 | KET Kehamilan Ektopik Terganggu | 120 | KRS. Keluar Rumah Sakit 121 | LA Local Anaesthesia I122 | LBP Low Back Pain { 123 | LP Lumbal Punctie 124 | Lat Lateral pore ene) 125 | LET Liver Funetion Test | 126 | LL Cast Long Leg Cast [ 127 | MOPP- Mechorethamine, Oncovin, Prednison, Procarbazine 128 | MRI ‘Magnetic Resonance Imaging | 129 | MRS ‘Masuk Rumah Sakit | 130 | MS ‘Mastektomi Simple { 131 | MRM ‘Modified Radical Mastektomi 132 [N Nervus 133 | NEC. ‘Necrotizing Entero Colitis, 134 | NHL ‘Non Hodgkin Lymphoma 135 | NICU Neonatal Intensive Care Unit 136 | NPC ‘Nasi Pharynx Carcinoma 137 | PA Postero-Anterior 138 | PA Patologi Anatomi 139 | PABI Persatuan Dokter Ahli Bedah Umum Indonesia 140 | PAL Periappendicular Infiltrat T 141 | PaO? ‘Tekanan Partial Oksigen Bila 142 | Pm _| Pro Renata — pertu | 143 | PSSW Pedicle Screw and Sublaminar Wiring | 144 | PSP Pedicle Screw Plate 145 | PSA Posteri Sagital Anoplasty | 146 | PCL | Posterior Cruciate Ligament _ - 147 | PCNL Percutaneus Nephrolithotomy 148 | PSAR Plasty __| Posteri Sagital Ano Rectoplasty _ 149 | RFT Renal Function Test | “150 | RGP Retrograde Pyelography [ 151 | RIND Reversible Ischemic Neurological Deficit | 152 | SB Tube Sengstaken Blackmore Tube 153 | RND Radical Neck Dissection 154] RS Rumah Sakit 155 | RT Rectal Toucher | 156 | SNH Stroke Non Hemorrhagic 157| SH Stroke Hemorrhagic 158 | SDH. Subdural Hematome 159 | SGB/ GBS ‘Syndroma Guillian Barre) GB Syndrome 160 | SCC. ‘Squamous Cell Carcinoma 161 | SIRS Systemic Inflammatory Response Syndrome 162. | SNNT Struma Nodosa Non Toksika 163 | Tb Tuberculosa 164 | THR Total Hip Replacement165 | TIA ‘Transient Ischemic Attack 166 | TN__ Trigeminal Neuralgia — 167 | TUR-B _| Trans Urethral Resection Buli buli | 168 | TUR -P | Trans Urethral Resection Prostate 169 | TKR, Total Knee Replacement [170 | TNM Tumor, Nodule, Metastase 171 | UL Urine Lengkap | 172 | USG Ultrasonografi | 173 | URS Uretero Renoscopy cal 174 | UTIL Urinary Tract Infection 175 | VP Shunt Venous Pressure Shunt | 176 | VC Vries Coup 177 | WSD Water Seal Drainage 178 | ft ‘Meningkat 1794 Menurun 180 | A/E Afek / Emosi 181 [ac ante coenam 183 | ai tas Indikasi : 184 | A/VC/D. Anemi / Ikterus / Cyanosis / Dyspnoe 185 | ACVD ‘Acute Cardiovascular Diseases | 186 | ADL’ Activity Daily Living a { 188 | ADL. Activities of daily living | 189 | Aeq ‘Aequalis = Sama / Homogen 190 | AF Atrial Fibrilation | 191 | AFO ‘Ankle Foot Orthose _ | 192 | AIDS ‘Acqured Immune Deficiency Syndrome 193 | AION Arteritic Ischemic Optic Neuropathy [194 [Ay ‘Angkat Jahitan 195 | AKMS Advokasi Komunikasi dan Mobilisasi social 196 | Akt Aktivir 197 | ALB Albumin 4 198 | ALL ‘Acute Lymphoplastik Leukimia | 199 | ALP Alkali Phospatase 200 | ALS Amyotrophic Lateral Sclerosis 201 | AML Acute Myelodyplastic / Myelositik Leukimia I 202 | Ant Anterior | 203 | ante coenam | Sebelum makan 7 = 204 | AP Akhir pengobatan 205 | Ap_ Appendicitis 206 | AP ‘Anterio-posterior 207 | APB Ante Partum Bleeding 208 | APF ‘Automatic processes Film — 209 | APG. Antegrade Pyelography _210 | APG II Anti Psikotik Generasi II | 211 | APTT Activated Partial Thromboplastin Time | 212 | AR Aorta Regurgitation _ I 213 | ARDS Acute Respiratory Distress Syndrome | 214 | ARK Auto Refracto Keratometer [ 215 | ART ‘Anti Retroviral Terapy | 216 | ARTI ‘Annual Risk of TB infection | 217 | ARV ‘Anti Retroviral (obat) 218 | AS Aorta Stenosis 219 | AS Ankylosing Spondilitis 220 | ASD | Atrial Septal defect 221 | ASHD Atherosclerotic Heart Disease 223 | Asteno ‘Astenozoospermia 224 | ATE _| Adeno Tonsitlectomy 225 | ATH _| Anak Tunggal Hidup 226 | AV Node Auricular Ventricular Node _— 227 | Azoo ‘Azoospermia 228 |B Bukal 229 | bid bis in die 230 | Ba/pi Batuk / Pilek 231 | BAB Buang Air Besar 232 | BAK Buang Air Kecil 233 | BB Berat Badan 234 | BBL Berat Badan Lahir 235 ____| Bayi Berat Lahir Rendah 236 | BBLR Bayi Berat Lahir Rendah _ 237 | BBLSR Bayi Berat Lahir Sangat Rendah 238 | BCG Bacillus Calmette et Guerin 239 | BCG Bacillus Calmette Gueren | 240 | BDE. ‘Belum Dapat Dievaluasi _ [ 241 | Bid bis in die = 2x sehari = 2 dd 1 | 242 | BI/M Bising Jantung (murmur) anne I 243 | BKB Batuk Kronis Berulang I 244 | BLK Balai Laboratorium Kesehatan _ [ 245 | BMK. Besar Masa Kehamilan | 246 | Bmp ‘Bone Marrow Punction 247 | BMR. Basal Metabolic Rate 248 | BOF Blas Overzicht Foto 249 | BOH [Bad Obstetric History 250 | BP. Bell's Pals} | 251 | BP Bronchopneumonia | 252 | BP4 Balai Pengobatan Penyakit Paru-Paru 253 | BRAO Branch Retinal Arteri Oclusion254 | BRVO Branch Retinal Vein Occlusion | 255 | BSO__ Bilateral Salpingo Oophorectomy £2 256 | BT Bleeding Time | 257 | BTA BasilTahan Asam 259 | BUN Blood Urea Nitrogen 260 |C Sendok Makan = 15 ml 261 | CL Color index 262 | CP | Cor/Pulmo 263 | Ca Carcinoma 264 | CABG Coronary Artery Bypass Grafting 265 | CBC Complete Blood Count 266 | CBC Complete Blood Count 267 | CC Common Cold | 268 | CDR. ase Detection Rate. 269 | CH Cholesterol t 270 | CHD Coronary Heart Disease | 271 | CHD Congenital Heart Disease 272|CHF Congenital Heart Failure 273 [CL Colon in Loop | 274 | Citiss Citiss = Cito = Segera | 275 | CM Caries Medialis _ L 276 | Cm Capreomycin 277 | CME Cystoid Macular Edema 278 | CNR ‘Case Notification Rate | 279 | COA ‘Camera Oculi Anterior | 280 | CoP Camera Oculi Posterior | 281 Corpus Alineum 282 Cerebral Palsy 283 Caries Profunda | 284 Cerebral Palsy __ | 285 Cephalopelvic Disproportion | 286 | CR Creatinin 287 [CR ‘Computerized Radiography | 288 | CRAO Central Retinal Arteri Occlusion 289 | CRP C Reactive Protein __| 290 | C-RP. C-reactive protein test 291 | CRS Cervical Root Syndrome 292 | CRS Cervical Root Syndrome 293 | CRT. Capillary Refill Time 294 | CRVO. Central Retinal Vein Oclusion 295 | CS Caries Superfisialis 296 | Cs Cycloserine | 297 | CT Clotting Time298 | CT SCAN Computed Tomography Scan | 299 | CTEV Congenital Talipes Equino Varus I 300 | CTG Cardiac Tocography | 301 | Cth ‘Sendok Teh= Sml 302 | CTS Carpal Tunnel Syndrome | 303 | CTS Carpal Tunnel Syndrome | 304 | Cum Cum = dengan 305 [CVA Cerebral Vascular Accident | 306 [CVA Infark | Cerebro Vascular Accident Infark 307 | CVAPIS Cerebro Vascular Accident PIS | 308 | CVP Central Venous Pressure [ 309 | Cvs Computer Vision Syndrome __ | [310 |D. Distal | 3u1{D Dextra = kanan I 312 | D.C.form Da cum formula = berikan sesuai formula | 313 [dd de die = sehari 314 | Did Da in dimidio = berikan separuhnya 315 | D.iduplo Da in duplo =berikan 2x nya 316 | dtd datales dosis 317 | D/ atau Dx Diagnosa 318|DBN Dalam Batas Normal 7 319 | DC Decompensation Cordist 320 | DC SHOCK _| Defibrilasi Cardiac Shock { 321 | DD Differensial Diagnosis 322 | DE —_| Disfungsi Ereksi - 323 | DHE, __| Dental Health Education 324 | DHF Dengue Hemorrhagic Fever | 325 | Disfs Disfungsi 326 | DL Darah Lengkap [ 327 | DMP. Dystrophia Musculorum Progressiva 328 | DMP Dystrophia Musculorum Progressiva 329 [DOA ‘Dead on arrival 330 | DOTS. Directly Obsreved Treatment Shortcourse Chemoterapy 331 | DS Diagnosa Sementara I 332 | DST Drug Sensitiity Testing | 333 | durante coenam | Pada Saat makan | [334 | ECCE Extra Capsular Cataract Extraction 335 |ECG/EKG _| Elektro Cardiography 336 | EDH_ Epidural Hematome | 337 | EDTA Etylen Diamine Tetracetic Acid | 338 | EEG Elektro Encephalography339 | BEM | Erythema exsudativa Multiforme [340 Ethmoidectomy Intranasal | 341 Ekstraksi Katarak Ekstra Kapsular 342 Ekstraksi Katarak Intra Kapsular 343 Erythema Nodosum Lepromatosum I 344 Episode 345 Extemal Quality Assurance System 346 Electrical Stimulation 347 Ethionamide 348 Cabut Gigi 349 Expirasi | 350 Extractie | 351 fac = fiant = fiat = buat / dibuat I 352 Fahrenheit 353 Faringitis Akuta 354 Fasilitas Pelayanan Kesehatan 355 Fungsional Class I 356 Fixed Dose Combination | 357 | FEFO First Expired First Out I 358 | FFA Fundal Fluoroscein Angiography 359 | FK Faringitis Kronis 360 | FS Frozen Shoulder 361 | FT Fisioterapi 362 | Fx Fracture 363 |G Gejala [ 364 |G Gram 365 | GA General Anesthesia 366 | Gama GT Gama Glutamic Transferase | 367 | GBS Guillane Barre Syndrome 368 | GCA Giant Cell Antertis 369 | GD 2 JPP Gula Darah 2 Jam Post Prandial | 370 |GDA/GDS | Gula Darah Acak/ Gula Darah Sewaktu [ 371 [GDM Gestasional Diabetes Mellitus | 372 | GDP Gula Darah Puasa 373 | GE Gastro-Enterology 374 | Gerdunas-TB _| Gerakan Terpadu Nasional Penangulangan Tuberculosa 375 | Ggan Gangguan oe 376 | GL Glass lonomer 377 | GL Gastro-Intestinal 378 | Gm Grams 379|GN_____| Glomerulonephrtis | 380 | GO Gonorthoe 381 | GP Gangren Pulpae382 383 rein = 65mg 384 Grains = 385 Glucose Tolerance Test 386 ‘hora = jam _ | 387 hora sommi = pada waktu mau tidur _ 388 Hepar / Lien 389 INH) Rifampicin/ Pyrazinamide/ Ethambutol 390 Hipermetropia + Presbiopia - 391 haustus = diminum sekaligus | 392 ‘Haemoglobin _ 393 | Hb | Hemoglobin, 394 | HBsAg Hepatitis B anigen 395 | Het Hematocrit 396 | Het Hematocrit = 397 | HDL. High Density Lipoprotein 398 | HDL. Hospital DOTS linkage 399 | HDT. Hapusan Darah Tepi 400 | HE Heart Failure 401 | HHD Hypertensive Heart Disease 402 | HHF Hypertensive Heart Failure 1 403 | HIV Human Immunodeficiency Virus 404 | HKAFO. Hip Knee Ankle Foot Orthose Hemia Nucleus Pulposus [406 | HNP | Hernia Nucleus Pulposus 407 | HP / HPP. Hiperemi Pulpa Perforasi 408 | HPG Hypothalamus - Pituitary ~ Gonad 409 | HPP Hemorrhagia Post Partum 410 | HR Heart Rate 411 | HRT ‘Hormone Replacement Therapy _ 412 | HSG "Hysterosalpingography 413 | HSP Henoch Schonlein Purpura 414 | HSVB High Social Value Baby 415 | HT Hipertensi eee | 416 | HZ0) Herpes Zoster Oticus AI7|1 Isi Pikir 418 /1&D Incison and Drainage 419 [id Ji. Intradermal / Intrakutan | 420 | LH. InfectiousHepatitis 2 [421 |im. Intramuskular _ 422 | 1M. Infectious Mononucleosus 423 | imam in manu medici = serahkan kembali ke dokter 424 | LO Intraoseus425 | iv. Intravena International Classification of Functional disability and 426 | ICF Health | 427 | ICIDH ae Classification of impairment, disability and | 428 | TFL Ikatan Fisioterapi Indonesi 7 I 429 | THD | Ischemic Myocard Acute 430 | IKATWI Ikatan Terapai Wicara Indonesia 431 | Tt Ikterus (bayi baru lahir) 432 | Im Intramuscular 433 | IMA Infarct Myocard Acute 434 [ INR International Normalized Ratio 435 | OPI Ikatan Okupasi Terapi Indonesia 436 | IOTI ikatan Ortotic Prostetik Indonesia | 437|1P Inritatio Pulpae - I 438 | IPA Ingin Punya Anak | 439 [IR Infrared Radiation Infeksi Saluran Kencing itereur = iteratio = diulang = ulangan Idiopatic Trombositopeni Purpura International Union Against TB and Lung Disease | Intrauterine Device | Intra Uterine Fetal Death ___| Indra Uteme Growth Retardation [ | Intravenous | Infeksi Virus Dengue Intra Venous Pyelography intravenous Pyelogram at Kapan Kembali Kontrol = ‘Kembali ke klinik (kontrol) Knee Ankle Foot Orthose | KBNP_ Kesalahan Besar Negatif Palsu | KBPP___| Kesalahan Besar Postitf Pals KD. Kejang Demam KDK Kejang Demam Kompleks KDS Kejang Demam Sederhana KDT Kombinasi Dosis Tetap KEK Kurang Energi Kronik Kel Keluhan 462 | KEP Kurang Energi Protein 463 | KET ‘Kehamilan Ektopik Terganggu 464 | KG | Kesalahan Gradasi 7 465 | KKNP Kesalahan Kecil Negatif Palsu | 46 | KKPP. Kesalahan Kecil Positif Palsu ea)467 | Km Kanamycin | Kecil Masa Kehamilan Kontrol Obat Habis Masih Sakit | [470 | KPD Ketuban Pecah Dini | 471 | KPP ‘Ketupan Pecah Prematur I 472 | KUB Kidney Ureter Bladder | 473 |L Lingual 475 | LBBB Left Bundle Branch Block 476 | LBBB Left Bundle branch block 477 | LBP Low Back Pain. 478 | LBP Low Back Pain 479 | LCS Liquor Cerebro Spinalis 480 | LD Laryngoscopy Directa 481 | LDL Low Density Lipoprotein LED/BBS/ Laju Endap Darah’ Bloed Bezinking Snelheid/ Blood 482 | BSR Sedimentation Rate 483 | LIO Lensa Intra Ocular 484 | LK Lingkar Kepala =a 485/LLD Left Lateral Decubitus — [486 |LLQ Left Lower Quadrant _ 487 | LP Lumbal Punksi 488 | LP Lumbal Punetion (Pungsi Lumbal) 489 | LP Lapang Pandang 490 | LPLPO- Laporan Pemakaian dan Lembar Permintaan Obat | 491 | LSCS Lower Segmen Cesarean Section 492 | LSO Lumbo Sacral Orthose 493 | LTG Low Tension Glaucoma 494 | LUQ Left Upper Quadrant | 495 | LVH Left Ventricle Hyperthropy | 496 | M Mesial 497 |M misce = eampur | 498[mf misce fac = campur, buatlah 7 499 | M+P_ Miopia + Presbiopia - 300 | MAE ‘Meatus Acusticus Externus 501 | MCH Mean Corpuscular Hemoglobin Mean Corpuscular Hemoglobin Concentrate ‘Mean Corpuscular Volume Millenium Development Goals 305 | MDR/XDR__| Multi Drugs Resistance’ Extensively Drug Resistance 506 | MDS Myelodysplastic Syndrome 507 | MI Mitral Insufficiency -508 | MMT Manual Muscle Test 509 |MO [isi Roeser nec 510 | MOP Medis Operatif Pria = EB 311 | MOTT Mycobacterium Other than Tuberculosis 312 | MOW Medis Operatif Wanita 513 | MR. Mitral Regurgitration 314 | MS Mitral Stenosis 515 [N Nadi 516 |N [Normal 517 Ni Ne iter = tidak diulang 518 | NS. ‘Normal Saline 519 | NAION | Non Arteritic Ischemic Optic Neuropathy 520 | NAW ‘Naso Anthral Window 521 | NCB Neonatus Cukup Bulan 522 | Neg Negative 523 | NG ‘Nyeri Gerak 524 | NKB ‘Neonatus Kurang Bulan 525 | NLB ‘Neonatus Lebih Bulan 526 | Nall Noduli Limfatia 527 | NSTEMI Non - ST Elevasi Myocard Infark 528 | NT Nyeri Tekan’ ei E 529 | NTG Normo Tension Glaucoma 530 | NTM Non Tuberculosis Mycobacterium 5310 ‘Oklusal 532 [ods | occulus dextra et sinistra = mata kanan dan kiri a 533 |O.H | Omni Hora = tiap jam 534 | OR. | Operating Room 535 | OA | Osteoarthritis 536 | OAT (Oligo - Asteno - Terato - Zoospermia 537 | OAT Obat Anti Tuberculosis — 538 | OCC ‘Occasional 539 | OCT Optical Coherence TomograpHy 340 | OD ‘Oophorectomy Dextra 541 | ODIOS. culo Dextra / Oculo Sinistra $42 | OGTT Oral Glucose Tolerance Test 43 | Oligo Oligozoospermia | 544 | OMA Otitis Media Akut_ 545 | OMC Otitis Media Chronica 546 | OMI Old Myocard Infarct = 547 | OMP- Otitis Media Purulenta 548 | OP Ortotik Prosthetik _ 549 | OROM. Oromycosis 550 | ORTU Orang tua / Keluarga a351 | OS Orang Sakit 552 | OS “Oophorectomy Sinistra aan 353 | OT Occupational Therapy _| 554 | PLA. Postero-anterior 555| pc. post coenam | 556 | P.O. per os 357 | pn Pro Renata | 558 | PAC Premature Auricular Contraction 559 | PB Panjang Badan (berbaring) [ | 560 | PB Proses Berpikir | 361 | PC Pulp Capping 362 | PCAG Primair Closed Angle Glaucoma 563 | PCOS Polycystic ovarii syndrome 364 | PCR Poly Chain Reaction 565 | PCV Paralysis Chorda Vocalis 566 | PDPI Persatuan dokter Paru Indonesia 575 | PERDOSRI__| Persatuan Dokter Spesialis Rehabilitasi Medik Indonesia 576 | PID Pelvic Inflammatory Disease 577 | PIM Periculum in mora =berbahaya bila ditunda | 578 | PIS Perdarahan Intra Serebral 579 | PIB Penyakit Jantung Bawaan 580 | PIK Penyakit Jantung Koroner 581 | PLT Platelet 582 | PME _ Pemantauan Mutu External 583 | PMI Pemantauan Mutu Internal 384 | PMO ‘Pengawasan Minum Obat I 585 | PNE Proprioceptive Nerve Fasclitation | 586 | POA Plan of action I 587 | POAG Primair Open Angle Glaucoma | 588 | Post Posterior 589 | post coenam —_| Sesudah makan 590 | PP Periode Pengamatan 591 | PP Paper Point 592 | PP | Pro Paurere = untuk masyarakat miskin 593 | PP Test Pregnancy Plano Test 397 | PPTL Perhimpunan Pemberantasan Tuberculosis Indonesia 598 | PR __| Pulmonalis Regurgitation z _| J | 599 | PRC Packed Red Cell 600 | PRM Premature Ruptur Membrane 601 | PRM Puskesmas Rujukan Microscopispro re nata = bila perlu Pulmonalis Stenosis — Puskesmas Satelit id 605 | PS/ Suportif | Psikoterapi Suportif 606 | PTA Peri Tonsilar Abcess 607 | PTCA Percutaneus Transcuminal Coronary Artery 608 | PTL Peri Tonsilar Infiltrat 609 | PTMC Percutaneus Transcuminal Mitral Commisurotomy 610 | PUA Perdarahan Uterus Abnormal 611 | PVC Premature Ventricular Tachycardia 612 | PVT Paroxysmal Ventricular Tachycardia 613 | Px Pasien 614/Q Quaque 615 [qd Quaque Day - 616 | qid Quart in Die 617 | qns. quantity not_sufficient 618 | qs quantum sufficiat = secukupnya 619 | qs quantity sufficient I 620 | Qid quart in die - 4x sehari = 4 dd 1 | 621 |R Recipe = ambillah 622 | R/ Resep — 623 | RA Rheumatoid Arthritis 624 | RBBB Right Bundle Branch Block 625 | RBBB Right Bundle branch block 626 | RBC Red Blood Cell | 627 | RBC RED Blood Cell 7 28 | RCT Root Canal Treatment | 629 | RD Retinopathia Diabetica | 630 | RDN Respiratory Distress of the Newborn | 631 | RDNP Retinopathia Diabetica Non Proliferatif 632 | RDP Retinopathia Diabetica Proliferatif 633 | RDS Respiratory Distress Syndrome [ 634 | RH Retinopathy Hypertension -_ [ (635 | RIND Reversible Ischemic Neurological Deficit aan 636 | Riw Riwayat | 637 | Rk Ronki 638 | RL_ Rhinotomy Lateralis 639 | RLD Right Lateral Decubitus | 640 | RLQ. Right Lower Quadrant 641 | RO"FO" Rontgen / Foto - 642 | ROM Rotation of Medication 643 | ROM/LGS __| Range of Motion / Luas Gerak Sendi [644 | ROP Retinopaty of Prematury645 | RPG Retrograde Pyelography 646 | RR ___| Respiration Rate 647 | RSP Rumah Sakit Paru | 648 | RTL, Reneana Tindak Lanjut 649 | RUQ Right Upper Quadrant | 650 | RUS 1 dan 2 | Rujukan Uji Silag Tingkat petrama & kedua | 651 | RVH Right Ventricle Hyperthrophy 652|S Sinistra = kin 653 |S Streptomycin 654 | SAH Sub Arachnoid Hemorrhage (655 | SAM Syndroma Aspirasi Mekonium 656 | Sat.tron Saturasi Iron 657 | SBE Sub Bacterial Endocarditis 658 | SC Sechio Caesaria 659 | SC Sectio Cesarea 660 | SC Scaling 661 | SCISK Subeutan / Subkutan 662 | SCI Spinal Cord Injury 663 | SCTP. Sectio Caesarea Trans Profunda | 664 | SD Salpingectomy Dextra [ 665 | SDE Sulit Dievaluasi | 666 | SDH Subdural Hematome | 667 | SGB/GBS___| Syndroma Gullian Barre / GB syndrome (668 | SGOT Serum Glutamic Oxaloacetic Transaminase 669 | SGOT Serum Glutamic Oxaloaceic Transaminase 670| SGPT Serum Glutamic Pyruvic Transaminase 671 | SGPT ‘Serum Glutamic pyruvic Transaminase 672 | st Serum Iron | 673 | SM Sinusitis Maxillaris 674 | SMA Sinusitis Maxillaris Acuta 675 | SMK ‘Sindroma Mata Kering 676 | SN Syndroa Nefrotik | 677|SO__ Serumen Obturans 678 | SOD Salpingo Oophorectomy Dextra | 679 | Soo Syndroma Otak Organik 680 | SOP, Space Occupying Process 681 | SOS Salpingo Oophorectomy Sinistra 682 | ss Salpingectomy Sinistra 683 | SSRI ‘Serotonine Selective reuptake Inhibitor 684 | ST/TW ‘Speech Therapy / Terapi Wi 685 | STEMI ‘ST Elevasi Myocard Infark 7 686 | Stom ‘Stomatitis687 | SVH Supravaginal Hysterectomy 688 | SVT Supraventicular Tachycardia 689 | SWD Short Wave Diathermy 690 | T ‘Temperatur 61 |T ‘Traktus 692 |T Testis 693 [T&A Tonsillectomy and Adenectomy 694 | tid Ter in Die 695 | T/ atau Tx Therapy 696 | TAH ‘Total Abdominal Hysterectomy 697 | TB Tinggi Badan 698 | TB Tuberculose 699 | TD Tonsilitis Diffusa [700/TE ——_| Tonsilectomy a= 701 | TENS ‘Trans Cutaneus Electrical Nerve Stimulation 702 | Terato Teratozoospermia 703 | Testos Testosteron_ 704 | TF Tetralogy Fallot 705 | TFA Tonsillo Faryngitis Acute 706 | TG Trigliceride 707 | TH ‘Tonsillo Hypertrophy 708 | THD ‘Trihexyphenidyl 709 | Thorax AP Thorax Antero Posterior 710 | Thorax Lat___| Thorax Lateral 711 | Thorax PA ‘Thorax Postero Anterior 712 | TIA ‘Transient Ischemic Attack 713 | TIBC Total Iron Binding Capacity 714 | Tid ter in die = 3x sehari = 3 dd 1 715 | TIO Tekanan Intra Oculair 716 | TK ‘Tonsilitis Kronis 717 | TLSO ‘Thoraco Lumbo Sacral Orthose 718 | TMG Three Mirror Gonioscopy 719 | TMJ ‘Temporo Mandibular Joint - 720 | TMI ‘Tempo Mandibular Joint 721 Trigeminal Neuralgia 72 Training Need Assessment | 723 | Te c ‘Tuba Ovaria Abses _ 724 | TOS ‘Thoracic Outlet Syndrome 725 | TP Total Protein 726 | TPHA ‘Treponema Pallidum Haemoaglutinasi 727 | TR Tricuspidalis Regurgitation 728 | TS Tricuspidalis - 729 | TS. Tambal Sementara730 | TSH Terapi Sulih Hormon BI Tidak Teraba == 732 Test Toleransi Glukose Oral (= OGTT) 733 | TTH Tension Type Headache 734 | TIN, ‘Transient Tachypneu of the newborn [ 735 | TTU Tidak Terukur | 736 | TUR ‘Trans-Urethral Resection | 737 [ue ‘Usus Externus = pemakaian Tuar | 738 | wi Usus Internus = pemakaian dalam 739 | UA Unstable Angina 740 [UA Urid Acid 741 | UGL Upper Gastro Intestinal 742 [UH Usia Kehamilan 743 | UL, Urine Lengkap 7 744 | US Ultrasound Diathermy 745 | USG Ultra Sonography 746 | USO Unilateral Salpingo Oophorectomy 747 | V.C Vertebra Cervical | 748 | V.LS Vertebra Lumbo Sacral | 749 | V.TL Vertebra Thoraco Lumbal 730 | Var Varikokel z 751 | VCSS ‘Vena Cava Superior Syndrome __ 752 | VDRL \Veneral Disease Research Laboratory 753 | VE Vacuum Extraction 754 | VH ‘Vaginal Hysterectomy a 735 | VKC Vernal Kerato Conjuetivitis 756 | VOD Visus Oculi Dextra 757 | VOS Visus Oculi Sinistra 758 | VSD Ventricular Septal Deffect 759 | WBC White Blood Cell | 760 | WBC White Blood Cell I 761 | Wh Wheezing (mengi) | 762 | WHO World Health Organization | 763 | ZN Ziehl NielsonSINGKATAN DIAGNOSA MEDIS, TINDAKAN, SIMBOL TANDA KHUSUS: BERDASARKAN UNIT KERJA, EDISI 2018 DI Rumah Sakit Sylvani BINJAT ORGANISASI PROFESL NAMA NO | ORGANISASI GELAR KET. PROFESL T | IKABI Tkatan Abii Bedah Mum Indonesia 2 |PAPDI | Persatuan Ahi Penyakit Dalam Indonesi 3. | PERKENT Perhimpunan Ahli Penyakit Dalam Indonesia 4 |PERDOSSI | Perhimpunan Dokter Spesialis Syaraf Indonesia [3 [Poar Perhimpunan Dokter Spesialis Obstetri Gynaecology Indonesia PDPT Persatuan dokter Paru Indonesia 8 | PPDGS Pedoman dan Penggolongan Diagnose Gangguan Jiwa 7 TO | PERDOSRI | Persatuan Dokter Spesialis Rehabilitasi Medik | Indonesia [ar Br "| Tkatan Bidan Indonesia 12 | PPNT Persatuan Perawat Nasional Indonesia 13 | PORMIKI Perhimpunan Profesional Perekam Medis dan Informasi Kesehatan Indonesia 14 [IDI Tkatan Dokter Indonesia | 1s | PDGr Persatuan Dokter Gigi Indonesia tT 16 | ISFI Tkatan Sarjana Farmasi Indonesia 17 | PAFT Persatuan Ahli Farmasi Indonesia 20 | IPAT Tkatan Perawat Anestesi Indonesia 21 | PATELRI | Persatuan Abli Teknologi Laboratorium Kesehatan 26 | PABI Persafuan Dokier Ahli Bedah Umum Indonesia 30 | PDPI Persatuan dokter Paru Indonesia _ R | Perhimpunan Ahli Telinga Hidung Tenggorokan dan 3_| PERHATIKL | pedah Kepala LeherDAFTAR SINGKATAN DIAGNOSA MEDIS, TINDAKAN, SIMBOL, TANDA KHUSUS, YANG DIBERLAKUKAN DI RUMAH SAKIT SYLVANI BINJAT (EDISI 2018) KOMPILASI DAFTAR SINGKATAN SIMBOL NO|__SINGKATAN KEPANJANGAN KET 110 Negatif - z 216 - Positif - = 3 |. Sama Dengan 4 |< Lebih Keeil Dari Ls Lebih Besar Dari 6s Lebih kecil Atau Sama Dengan 7 [= Lebih Besar Atau Sama Dengan Bit Menurun_ 9 \t Meningkat = 10_| SFU 5 Fluorouracil - DAFTAR SINGKATAN YANG TAK BOLEH DIPAKAI DI RUMAH SAKIT SYLVANI BINJAL. (DON'T USE LIST) - 2018 TAK BOLEH | POTENSIAL NO DIPAKAIL BERMASALAH KESEPAKATAN 1 [BS Mg Meg |AD,AS,AU_ | OD,05,0U Tetinga kanen, linge ki, masing-masing 5 | telinga outs ours lapeactan, Mata kanan, mata kiri, masing-masing 3 _ o_o mata 4 [wu TV atau 10 Internasional unit 3 [QD QiD Daily /tiap hari 6 |QOD QdatauQLD | Every other day /tiap 2 hari sekali 7 |v 0, 4 atau ce Unit 8 | SCSQsubq | SL, S every Subkutan 9 [Ce u (unit) MI 10 | Mgso4 Morphine sulfate Magnesium sulfate 11_|MS,MSO4 | Magnesium sulfate | Morphine sulfate 12 [MTX Mitoxantrone Methotrexate 13 | PTU Mercaptopurine Propylthiouracil 14 | ZnS04 Morphine sulfate | Zine sulfate ea 15 | 1,0mg/1.0 mg | 10mg T mg16 | Smg Sime 0,5 mg Kp (kal a no a Kp -Koch Pulmonum | pm (pro renata) Direktur Rumah Sakit Sylvani Binjai dr. Dovi Camela Sitepu, M.Kes