DAFTAR ISI

BAB I PENDAHULUAN
A. Pendahuluan .............................................................................................. 1
B. Maksud dan Tujuan .................................................................................... 2
BAB II KEBIJAKAN REKAM MEDIS
A. Pengertian Rekam Medis ............................................................................ 3
B. Sifat Rekam Medis ...................................................................................... 3
C. Tujuan Rekam Medis .................................................................................. 3
D. Kegunaan Rekam Medis ............................................................................ 4
E. Isi Rekam Medis ......................................................................................... 5
F. Pembrian Nomor Rekam Medis .................................................................. 7
G. Sistem Identifikasi Pasien ........................................................................... 8
H. Penyimpanan Rekam Medis ....................................................................... 9
I. Penyusutan dan Pemusnahan Rekam Medis ............................................... 10
J. Peminjaman Rekam Medis .......................................................................... 10
K. Pemeliharaan Berkas Rekam Medis ........................................................... 10
L. Prosedur Pendaftaran Pasien Baru ............................................................. 10
M. Prosedur Pendaftaran Pasien Lama .......................................................... 11
N. Prosedur Pendaftaran Pasien Rawat Inap .................................................. 11
O. Informed Consent ...................................................................................... 12
P. Pengembalian Berkas Rekam Medis .......................................................... 13
Q. Pembuatan Visum Et Repertum ................................................................ 13
R. Pertanggungjawaban Terhadap Berkas Rekam Medis ............................... 13
S. Siatem Pelaporan Data ............................................................................... 15
T. Penulisan Simbol, Singkatan dan Tanda Khusus Rekam Medis ................. 15
BAB III ORGANISASI REKAM MEDIS
A. Bagian Rekam Medis .................................................................................. 16
B. Kelompok Kerja (Pokja) Rekam Medis ....................................................... 26
BAB IV PROSEDUR PENYELENGGARAAN REKAM MEDIS
A. Sistem Rekam Medis .................................................................................. 28
B. Prosedur Penyelenggaraan Rekam Medis ................................................. 35
C. Kegiatan Pencatatan Rekam Medis ............................................................ 40
D. Proses Pengolahan Rekam Medis .............................................................. 40

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BAB V ASPEK HUKUM REKAM MEDIS
A. Pertanggungjawaban Rekam Medis ........................................................... 48
B. Kepemilikan dan Kerahasian Rekam Medis ............................................... 49
C. Pelepasan Isi Rekam Medis ....................................................................... 50
D. Persetujuan Tindakan Medis (Informed Consent) ....................................... 51
BAB VI PENULISAN SIMBOL DAN SINGKATAN PENYAKIT
A. Simbol Umum ............................................................................................. 60
B. Singkatan Diagnosa Penyakit dan Tindakan ............................................... 61
C. Istilah Umum............................................................................................... 66
D. Singkatan Tindakan .................................................................................... 68
BAB VII PENUTUP

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