BAB I

DEFINISI

Pemberian kode adalah pemberian penetapan kode dengan

menggunakan huruf dan angka atau kombinasi huruf dan angka yang
mewakili komponen data. Definisi adalah suatu batasan atau arti, bisa juga
dimaknai kata, frasa, atau kalimat yang mengungkapkan makna, keterangan,
atau ciri utama dari orang, benda, proses, atau aktivitas. Simbol adalah
lambang yang digunakan untuk menunjukkan obyek yang dituju atau yang
dimaksud, Singkatan adalah kependekan kata atau kata ringkasan dari suatu
kalimat baik itu berupa kalimat pada umumnya, diagnosa maupun tindakan.
Untuk menertibkan dan melengkapi informasi berkas Rekam Medis
baik Rawat inap, rawat jalan dan IGD perlu menyeragamkan dan
menyamakan persepsi mengenai kode diagnose,kode prosedur/tindakan,
definisi , simbol yang digunakan dan yang tidak boleh digunakan, singkatan
yang digunakan dan tidak boleh digunakan di RSUD SMC Kab Tasikmalaya
Untuk mengetahui kesesuaian penulisan istilah medis yang tercantum dalam
berkas rekam medis sesuai dan seragam oleh seluruh praktisi yang
berkecimpung di pelayanan kesehatan RSUD SMC Kab Tasikmalaya sebagai
bahan acuan dalam pengisian berkas Rekam Medis.

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 BAB II
RUANG LINGKUP

Ruang lingkup dari standarisasi kode diagnose,kode prosedur/tindakan,

definisi , simbol yang digunakan dan yang tidak boleh digunakan, singkatan
yang digunakan dan tidak boleh digunakan di RSUD SMC Kab Tasikmalaya
adalah:

1. Direktur RSUD SMC kab Tasikmalaya, sebagai pengambil keputusan

tertinggi
2. Instalasi Rekam medis
3. Panitia Rekam Medis
4. PPA ( Profesional Pemberi Asuhan ) dan tenaga lain yang mempunyai
akses dalam pengisian rekam medis

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 BAB III
TATA LAKSANA

STANDARISASI KODE DIAGNOSIS YANG DIGUNAKAN

Nama Diagnosis Kode ICD-X

Aberrant conduction / disorder conduction I45.9
Abortus imminent (threatened abortion) O20.0
abortus incomplete O06.4
Abrasi gigi K03.1
Abscess Anal K61.0
Abscess Inguinal L02.2
Abscess intra abdomen K65.0
Abscess Liver K75.0
Abscess mamae N61
Abscess of Appendix K35.1
Abscess Pedis L02.4
ABSCESS PERIODONTAL K05.2
Abscess peritoneum K65.0
Abscess Prostate N41.2
Abscess scrotum (S) N49.2
ABSCESS TOOTH K04.7
ABSES HEPATIC K75.0
ABSES MANDIBULA K07.0
Acidosis Metabolic E87.2
ACNE KONGLOBATA L70.1
Acne Vulgaris L70.0
ACUTE ANTERIOR MYOCARDIAL INFARCTION I21.0
Acute inferior MI I21.1
Acute kidney injury (AKI) S37.0
Acute myeloid leukaemia (AML) C92.0
Acute Myocardial Infarction (AMI) I21.9
ACUTE NEPHRITIC SYNDROME N00.9
Acute Severe Asthma J46
ADB (Anemia Deficiency Besi) D50.0
ADHD (ATTENTION DEFICIT HYPERACTIVITY
DISORDER) F90.0
Adhesion jaringan (pelvic) K66.0

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Adhesion of ovari N73.6
Adhesions Abdomen K66.0
Adnexitis N70.9
AF I48
AFP HECTING Z48.0
AHC H52.2

AIDS (Acquired immunodeficiency syndrome) B24

AIHA (Autoimmune hemolytic anemia) D59.1

AKI (Acute kidney injury) N19
ALL (Acute Lymphocytic Leukemia) C91.0
Allergic Food T78.1
AMC (Astigmatismus hypermetropicus
compositus) H52.2
AMENORRHAE PRIMARY N91.0
AMENORRHAE SECONDARY N91.1
AMI anterior wall I21.0
AML (Acute myeloid leukaemia ) C92.0
Amoebiasis Acute A06.0
Amoebiasis, Unspecified A06.9
ANC (Antenatal Care) Z34.9
Anemia D64.9
Anemia aplastic D61.9
Anemia deficiency Fe D50.9
Anemia Neoplastic D63.0
Aneurysm Aorta Abdominal I71.4
Angina Pectoris I20.9
Anorexia R63.0
Anorexia Nervosa F50.0
Anxiety / GANGGUAN KECEMASAN / CEMAS F41.9
AP / ANGINA PECTORIS I20.9
APBDSB (asthma persisten berat dalam
J46
serangan berat)
aphakia H27.0
Aphasia and dysphasia R47.0
Apnea R06.8
APP (Appendicitis) K37
APP SUBAKUT K36
Appedicitis perforation K35.0
Appendicitis acute K35.9
Appendicitis Chronic K36
Appendicitis Infiltrat K35.1
Appendicitis, unspecified K37

4
Appendicitis,perforasi K35.0
Appendicitis,peritonitis K35.9
APS (Angina Pectoris Stable) I21.9
AR (Aortic Regurgitation) I35.1
ARF (Acute Renal Failure) N17.9
Arhtrosis of knee (Gonarthrosis) M17.9
Arrhythmia I49.9
Artery thrombotic I74.9
Arthralgia, pain in joint M25.5
ARTHRITIS M13.9
Arthritis Septic M00.9
Arthrosis, Unspecified M19.9
Ascites R18
ASD-PH (atrial septal defect-pulmonary
hipertension) Q21.1
ASMA BRONCHIALE J45.9
ASMA CARDIAC I50.1
Asphyxia R09.0
Asphyxia berat (severe birth asphyxia) P21.0
Asphyxia mild-moderate P21.1
Asphyxia Neonatal (Birth Asphyxia) P21.9
ASPIRASI PNEUMONIA J69.0
asthenia R53
ASTHENOPIA H53.1
Asthma Bronchial J45.9
Atherosclerosis aorta I70.0
Atonia Uteri O62.2
Atresia ani, anus Q42.3
Atresia billiary (atresia bile duct) Q44.2
Atrial fibrillation and flutter I48
Atrial septal defect (ASD) Q21.1
Atrophy cerebri G31.9
Auditory hallucinations R44.0
Autoimmune Disease M35.9
Autoimmune hemolytic anemia (AIHA) D59.1
Azotemia R79.8
Non AIHA D59.4

Bell's palsy, paralisis G51.0

Bangkitan tonic clonic G40.3

5
Barret's esophagus, Ulcer esophagus K22.1
Batu letak ginjal (staghorn), calculus kidney) N20.0
batu ureter jg batu ginjal N20.2
BATUK / cough R05
BBL sc (Bayi Baru lahir seksio cesarean) P03.4
BBL spontan Z38.0
BCA (Bronchitis Asthmatis) J45.9
BE (Bronchiectasis) J47
BENGKAK KAKI R60.0
Benign Prostate Hyperplasia (BPH) N40
Berat bayi lahir rendah (BBLR=1000<X<2500
P07.1
g)
Berat bayi lahir sangat rendah (BBLSR=X<999
kg) P07.0
Beriberi E51.1
BESER/INCONTINENCE R32
BKB / BATUK KRONIK BERULANG R05
BL a.i. KPD P01.1
BL a.i. prolonge labor (partus tak maju) P03.8
BL dengan VE (Vacum Extraction) P03.3
BL dengan bayi besar P08.0
BL dengan forceps P03.2
BL dengan induksi P03.8
BL dengan komplikasi persalinan P03.9
BL dengan SC P03.4
BL letak sungsang before labor P01.7
BL letak sungsang during delivery P03.0
BL post-term (>42 minggu) P08.2
BL premature (28<X<37 minggu) P07.3
BL sc a.i. CPD P03.1
BL sc a.i. Gemeli P01.5
BL sc a.i. HAP P02.1
BL sc a.i. ibu asthma bronchiale P00.3
BL sc a.i. letak oblique P03.1
BL sc a.i. PEB (Pra-eklamsi Berat) P00.0
BL sc a.i. placenta praevia P02.0
Blepharitis H01.1
Blighted ovum and nonhydatidiform mole / BO O02.0
BP (Bronchopneumonia, unspecified, perinatal
P28.9
period, resoiratory condition of newborn)
BPH (Benign Prostate Hyperplasia) N40
BPPV (Benign Paroxymal Vertigo) H81.1

6
Bradycardia, unspecified (slow heart beat) R00.1
bromhidrosis l75.0
Bronchiectasis (Bronchiolectasis) J47
Bronchiolitis acute, unspecified J21.9
Bronchitis acute, unspecified J20.9
BRONCHITIS ALERGI J45.9
Bronchitis anak J20
BRONCHITIS CRONIS J42
Bronchitis, unspecified (dewasa) J40
Bronchopneumonia, unspecified J18.0
Bronchopneumonia, unspecified, perinatal
period, resoiratory condition of newborn P28.9
Bronchospasm J98.0
broncialgia (nyeri lengan) M79.6
BRP (Bronchiectasis Pneumonia) J18.9
BRVO / BRANCH RETINAL VEIN OCLUSSION H34.8
BSK / BATU SALURAN KEMIH N20.1
BTC (Bangkitan Tonic Clonic G40.3
BURGER'S DISEASE I73.1
Bursitis M71.9
Bursitis calcaneal M77.5

Cancer pain R52.9

Ca Bulli / Bladder C67.9
Ca Caput pancreas (head of pancreas) C25.0
Ca Cervix C53.9
Ca Colon C18.9
Ca Colon Descending C18.6
CA LIDAH C02.9
Ca Liver C22.9
Ca Mamae C50.9
Ca Mamae Metastatic C79.8
Ca Mamae/IDCM C50.9
Ca nasopharynx, unspecified/ NPC C11.9
Ca ovari C56
Ca Parotid C07
Ca paru C34.9
Ca prostate C61
Ca Recti, unspecified C20

7
Ca Spondylosis (vertebral, column), metastatic C79.5
Ca Testis C62.9
Ca TONSIL C09.9
Ca Vulva C51.9
CAD (coronary artery disease) I25.1
CALLUS / CLAVUS L84
Campak (measles) B05.9
Cancer riwayat Kemoterapi Pro Operasi Z40.0
CANDIDIASIS INTERTRIGO B37.2
Candidiasis Newborn P37.5
CANDIDIASIS ORAL B37.0
B37.3+
Candidiasis Vagina N77.1*
Candidiasis, unspecified B37.9
CAP (Community-Acquired Pneumonia) J18.9
Caput succedaneum P12.8
Cardiac arrest, unspecified I46.9
Cardiac cirrhosis K76.1
CARDIOCHALASIA K21.9
Cardiomegaly I51.7
Caries dental, unspecified K02.9
CARPAL TUNNEL SYNDROME/CTS G56.0
Caruncle Urethra N36.2
cavsd / complete atrioventricular septal defect Q21.2
CC (Contusion Cerebri) S06.2
Cek lab Z01.7
Cellulitis antebrachi (lengan bawah/arm) L03.1
Cellulitis Toe L03.0
Cephalgia R51
Cephalopelvic disproportion (CPD) O33.9
Cerebral Palsy (CP) G80.9
Cerumen H61.2
CERVICAL ROOT DISORDER G54.2
cervical syndrome M53.1
CERVICITIS N72
CH (Cirrhosis hepatis) K74.6
Chalazion H00.1
CHD (Coronary Heart Disease) I25.9
CHEST PAIN R07.4
CHF (Congestive Heart Failure) I50.0

8
CHF, HT, CKD I13.2
CHF, HT, HHD I11.0
Chikungunya fever A92.0
CHL / CONDUCTIVE HEARING LOSS H90.2
Chocolate cyst (ovary) N80.1
Cholecystitis Acute K81.0
Cholecystitis, unspecified K81.9
Cholecystolithiasis K80.2
Choledocholithiasis, cholangitis K80.3
Choledocholithiasis, cholecystitis K80.4
Choledocolithiasis K80.5
Cholelithiasis (batu empedu), without
cholecystitis K80.2
Cholelithiasis, cholecystitis K80.1
CHOLESTASIS K83.1
Chrohn's Disease K50.9
Chronic kidney disease (CKD) N28.9
Chronic obstructive pulmonary disease (COPD),
unspecified J44.9
Cirrhosis hepatis (CH) K74.6
CKD (Chronic Kidney Disease) N28.9
Clavus L84
CLL (Chronic Lymphocytic Leukemia) C91.1
CLL (CHRONIC LYMPHOCYTIC LEUKEMIA) C91.9
Cluster headache G44.0
CML (Chronic Myelocitic Leukemia) C92.1
Coagulation D68.9
coagulation post partum O72.3
Colic Abdomen R10.4
Colic renal N23
Colitis Ulcerative K51.9
COMBUSTIO T30.0
Common Cold J00
Community-acquired pneumonia (CAP) J18.9
Concusion syndrome F07.2
Condyloma acuminatum a.r. Perianal A63.0
CONGENITAL HEART DISEASE/ CHD CYANOTIC Q24.9
Congestive hepatopathy K76.1
CONJUNGTIVITIS H10.9
Conjungtivitis neonatal P39.1
CONTUSIO T14.0
CONTUSIO DADA S20.2
Contusio Renal S37.0

9
Convalescence (Pemulihan kesehatan) Z54
Convulsions Of Newborn P90
COPD (Chronic Obstructive Pulmonary Disease),
J44.9
unspecified
COPD exacerbation acute J44.1
Coronary heart disease (CHD) I25.9
CORPAL / BENDA ASING MASUK MULUT T18.0
Corpus Alineum T18.9
Corpus esophagus T18.1
Corpus pharynx/nasopharynx T17.2
COXITIS MONOARTHRITIS NEC M13.1
CP (Cerebral Palsy) G80.9
CPC (Cor Polmunale Chronic) I27.9
CPD (Cephalopelvic Disproportion) O33.9
cramps / kram R25.2
CRF (Chronic Renal Failure), unspecified N18.9
CRF, HT, insufficiency renal I12
Crushing syndrome (complication of trauma) T79.5
CRVO H34.8
Cushing Syndrome E24.9
CYST arytenoid J38.7
Cyst atheroma, cyst dermoid a.r bahu D23.6
Cyst atheroma, cyst dermoid a.r dada (chest
wall) D36.7
Cyst Dermoid D23.9
Cyst Hepar K76.8
Cyst of Bartholin's gland (kista bartolin) N75.0
Cyst of kidney N28.1
Cyst orbital H05.8
Cyst ovari/KISTA OVARI N83.2
Cyst Sebaceous L72.1
Cyst Thyroglossal Q89.2
Cystitis N30.9
Cystitis, vesicolithiasis N21.0
TUBA ATRAL / CERUMEN TELINGA H61.2

DCA/DIARE CAIR AKUT A09

Decompensation cardiac (decom cordis) / DC I51.9
dehisensi operation wound T81.3
Dehydration E86
Dehydration of newborn P74.1

10
DELIRIUM/ PENURUNAN KESADARAN F05.9
Dementia F03
Dementia Vascular, unspecified F01.9
Dependence on renal dyalisis (ketergantungan Z99.2
hemodialisa), ESRD
DERMATITIS L30.9
dermatitis alergi L23.9
Dermatitis Atopic L20.9
Dermatitis bullosa L13.9
Dermatitis contact, allergic L23.9
DERMATITIS NUMULARIS L30.0
Dermatitis seborrheic L21.9
Dermatomyositis M33.1
DHF A91
Diabetic nephropathy E14.2
Diabetic Polyneuropathy E14.4+G63.2*
Diaper rash (luka lecet di anus) L22
Diarrhea Chronic K52.9
Diarrhoea acute A09
Diarrhoea neonatal P78.3
DIC (disseminated intravascular coagulation) D65
DIH (Drug Induced Hepatitis) K71.6
DILATED LA I51.7
Dislipidemia (disorder lipoprotein metabolism) E78.9
Dislocation of hip (dislokasi panggul) S73.0
Dislocation of septal cartilage nose (dislocation S03.1
septum)
DISMENOR N94.6
Diverticullar Bulli N32.3
DJ STENT Z96.0
DKA (Dermatitis Contact Allergic) L23.9
DKD (DIABETIC KETOACIDOSIS) E10.1-E14.1
DKI (Dermatitis Contact Irritant) L24.9
DM (Diabetes melitus), unspecified E14.9
DM type 1, non-insulin dependent E10.9
DM type 2, insulin dependent E11.9
DM,gangrene E14.5
DM,neuropathy E14.4+N08.3*
DOA R98
Double collecting system (dua ginjal, bawaan) Q63.0
Down Syndrome Q90.9
DRA (Demam Rheumatic Akut) I00

11
Drug alergi T88.7
Drug Eruption L27.0
DRUG INDUCED HEPATITIS K71.-
drug induced liver injury / DILI k71.9
DSS / DENGUE SHOCK SYNDROME / DHF A91
DUB (Dysfunction Uterus Bleeding) N93.8
DVT (Deep Vein Thrombosis) I80.2
Dysentri Baciler, Dysentery Bacillary A03.9
Dysfuction hepar K76.8
DYSPHAGIA R13
DYSPLASIA MAMARY N60.9
Dyspneu R06.0
Ulcus Decubitus L89

EDH (Epidural haemorrhage) S06.4

E Colli infection A04.4
Edema R60.9
Edema paru (pulmonary oedema) J81
Edentulous ridge (Ridge, Disease, edentulous) K06.9
EF (Encephalopathy Hepaticum) K72.9
Effusion pleura J90
Efusi pericarditis I31.9
Eksim / Eczema L30.9
EL (Emphysema Lung) J43.9
Emphysema subcutaneous T79.7
Emphysema, unspecified J43.9
Encephalopathy hepaticum (Hepatic failure,
unspecified) K72.9
Encephalopathy hepaticum gr IV K72.1
Encephalopathy, unspecified G93.4
End stage renal disease (ESRD) N18.0
Enteritis chronic K52.9
EPA (Edema Paru Akut) J81
Epidural haemorrhage (EDH) S06.4
EPIGASTRIC PAIN R10.1
Epiglottitis acute J05.1
Epilepsy, unspecified G40.9
Epistaxis R04.0
EPULIS (GIGI) K06.8
Eruption in tooth K00.6

12
ESRD (End stage renal disease) N18.0
EVAN SYNDROME D69.3
Exanthema Subitum B08.2

Fistula in ano (anal fistula) K60.3

FIBROMA D21.9
FAM (Fibroadenoma Mamae) D24
Fibrodysplasia mamae = FAM D24
Febrile Neutropenia D70
fistula pada aurikel G61.1
FANC H60.9
FISTULA AURICLE H61.1
perforation membrane tymphani H72.9
FUNDUS VARICES / GASTRIC VARICES I86.4
FISSURE ANAL K60.2
Fistula in ano (anal fistula) K60.3
Fatty Liver K76.0
FOLLICULITIS L73.9
freckles l81.2
Fasciitis plantaris M72.2
Frozen Shoulder M75.0
FMS (Fibromyalgia Syndrome) M79.0
Fibrocystic of the breast N60.1
False labour, hamil dipertahankan O47
FTT (Failure To Thrive) /gagal tumbuh, newborn P05.9
Febris (newborn) P81.9
Flatulence (meteorismus) R14
FUO / FEVER of UNKNOWN ORIGIN R50.9
fatigue R53
fs / frailty syndrome R54
Febrile convulsion (FS) / FC / Kejang Demam R56.0
FTT (Failure To Thrive) /gagal tumbuh R62.8
Fracture frontal S02.0
Fracture of base skull S02.1
Fracture Nasal S02.2
Fracture maxilla S02.4
Fracture Gigi S02.5
FRACTURE VERTEBRA THORACIC S22.0

13
Fracture Rib (tulang rusuk) S22.3
Fracture Scapula S42.1
Fracture humerus (shaft) S42.3
FRACTURE ANTEBRACHI S52.9
Fracture metacarpal S62.3
Fracture Hand S62.8
Fracture Collum Femur S72.0
Fracture Femur S72.9
Fracture tibia proximal S82.1
Fracture Fibula tibia S82.2
Fracture Tibia S82.3
Fracture Metatarsal S92.3
Fracture vertebra T08

Geriatri/senility R54
GEA A09
GBM(Glioblastoma Modifier Brain) C71.9
GANGGUAN KOAGULAN D68.9
GRAVES DISEASE E05.0
GANGRENE DM E14.1
GAD (Generalized Anxiety Disorder) F41.1
GBE (GANGGUAN BAHASA EKSPRESIF) F80.1
GBS (Guillain Barre Syndrome) G61.0
GRANULOMA TELINGA H71
GP (Gangrene Pulpa) K04.1
Gingivitis Acute K05.0
Gingivitis chronic K05.1
GERD (Gastroesophagus Reflux Disease) K21.0
Gastritis acute K29.1
Gastritis Erosive K29.1
Gastritis chronic K29.5
Gastritis K29.7
GASTROPATHY LANZA KLS III K31.7
Gastropathy lanza K31.8
Gastropathy NSAID K31.9
GASTROPATY K31.9
Granuloma L92.9
Gout arthritis M10.0
Gout, unspecified M10.9

14
Ganglion /GCT M67.4
GNA (Glomerulus Nephritis Acute) N05.8
GGK (Gagal Ginjal Kronis)/ESRD N18.0
Gynecomastia N62
Galactocele N64.8
GCU (General check up) Z00.0
Ginecology (ada kelainan) Z71.9

Herniasi otak G93.5

HFMD (Hand Foor Mouth Disease) B08.4
Hepatitis A B15.9
Hepatitis B B16.9
Hepatitis C B17.1
Hepatitis Virus Akut B19.9
HCC (Hepatocellular carcinoma / hepatoma) C22.0
HEMANGIOMA D18.0
Hygroma (lymphangioma) D18.1
HSP (Henoch Schonlein Purpura) D69.0
HYPERSPLENISM D73.1
Hyper IgE Syndrome (HIES) D82.4
HYPERTIROID E05.9
HONK (hyperosmolar non keton) E10-E14
Hypoglicemia E16.2
Hypercholesterolemia E78.0
HYPERTRIGLYCERIDEMIA E78.1
Hyperlipidemia E78.5
Hyperuricemia E79.0
Hyperphospatase E83.3
Hypercalcemia E83.5
Hypernatremia E87.0
Hyponatraemia E87.1
Hyperkalaemia E87.5
Hypokalaemia E87.6
Hyperchloremia E87.8
Hypoalbuminemia E88.0
HERPRES B00.9
Hemiplegia (hemipharesis) G81.9
HCP (Hydrocephalus, unspecified) G91.9

15
hypermetropia simplex (HS) / hypermetropia H52.0
HEARING LOSS H91.9
HYPERTENSI GR I I10.0
HYPERTENSI GR II I10.1
HHD ( hypertension heart disease ) I11.9
HRD (Hypertension Renal Disease) I12.9
Hemorrhoid internal I84.2
Hemorrhoid External I84.5
Hemorrhoid external I84.5
HEMOROID I84.9
HRB (Hypereaktifitas Bronchus) j98.0
HYPESPLENISME K04.1
Hemel (hematemesis melena) K27.4
HIL incarcerated K40.3
HIL (Hernia inguinal lateralis) K40.9
Hernia femoral K41.9
Hernia Hiatal K44.9
Hepatitis acute K72.0
Hepatitis reaktif K75.2
Hepatorenal insufficiency, failure hepatorenal K76.7
Hepatoptosis K76.8
Hepatopathy reaktif K76.9
Hematemesis K92.0
HPI / hyperpigmentation inflamatory L81.0
HYPERPIGMENTASI/ HP L81.8
Hemarthrosis M25.0
HNP (Hernia nucleus pulposus) M51.2
Hydronephrosis, stenosis ureter N13.1
Hyronephrosis, nephrolithiasis, ureterolithiasis N13.2
Hydronephrosis N13.3
Hydrocele testis N43.3
Hydrosalpinx, Chronic salpingitis and oophoritis N70.1
Hematoma retrouterine (di belakang uterus) /
N83.7
hematoma brod ligament
Hyperplasia endometrium N85.0
HDK (HYPERTENSION DALAM KEHAMILAN) O16
HEG (Hyperemesis Gravidarum) O21.0
Hemorrhoid in pregnancy O22.4
HAP (Hemorrhagic Ante Partum) O46.9
hpp / hemorrhagic post partum O72.-
Hyperthyroidism in pregnancy O99.2
HIE (Hypoxia Ischaemic Encephalophathy) P21.9
HMD (Hyaline Membrane Diseased) P22.0

16
HDN (Hemolytic disease of the newborn) P53
Hyperbilirubinemia P59.9
Hirschsprung's Q43.1
Hypospadia type midshaft + cordee Q54.4
Hypospadia Q54.9
Hemaptoe, hemoptysis R04.2
Hiccup / hicough CEGUKAN R06.6
HEPATOMEGALY R16.0
Hematuria R31
Hyperglycemia R73.9
Hematoma subguleal (scalp) S00.0
Hematoma sinus bilateral S00.3
Hemorrhagic postoperative (perdarahan post
operasi / tindakan) T81.0
HEMODIALYSIS Z49.1

ILI (Influenza Like Ilness) J11.1

IBD (Inflamatory bowel disease) K63.9
IBS (Irritable Bowel Syndrome) K58.9
ICH (Intra cranial Hemorrhage) I62.9
ICHTHYOSIS Q80.9
ICHTHYOSIS SIMPLEX Q80.0
Ichthyosis Vulgaris Q80.0
IDCM (Invasive Ductal Carcinoma Mamae) C50.9
Idiopathic peripheral autonomic neuropathy /
G90.0
Carotid sinus syncope (system carotid kiri)
Idiopathic thrombocytopenic purpura (ITP)
(evan's syndrome) D69.3
IGT / IMPAIRED GLUCOSE TOLERANCE R73.0
IHD (Ischemic Heart Disease) I25.9
ILEUS K56.7
Ileus obstructive K56.6
Ileus obstructive, adhesi abdomen K56.5
Ileus Paralytic K56.0
Imbalance electrolyte E87.8
Impacted tooth K01.1
IMPETIGO L01.0
IMUNISASI Z26.9
IMUNISASI BCG Z23.2
IMUNISASI CAMPAK Z26.8

17
IMUNISASI DTP + POLIO Z27.3
IMUNISASI HEPATITIS Z24.6
IMUNISASI POLIO Z24.0
IMUNISASI SYNFLORIX Z25.8
Incomeplete right bundle branch block (IRBBB) I45.4
Incontinence urine R32
ineruption tooth K01.1
Infeksi Neonatal P39.9
Inferior MI,ischemic inferior I21.1
INFERTILITAS SEKUNDER N97.9
Injury Head S09.9
Injury kidney S37.0
Injury of small intestine, ileum S36.4
INSECT BITE T14.0
INSOMNIA G47.0
Insufficiency renal N19
INTOKSIKASI ALKOHOL F10.0
Intra cranial hemorrhage (ICH) I62.9
Intra uterine growth rate (IUGR) O36.5
intra ventricular hemorrhage (IVH) I61.5
IRBBB (Incomeplete right bundle branch bloc) I45.4
IRRITABLE BOWEL SYNDROME (IBS) K58.9
Ischemic heart disease (IHD) I25.9
Ischialgia (sciatica) M54.3
ISK (Infeksi saluran kemih)/UTI N39.0
ISK pada kehamilan O23.4
ISPA SAAT HAMIL O99.5
ISPA/URTI (Infeksi Saluran Pernafasan Atas) J06.9
ITP (Idiopathic thrombocytopenic purpura )
D69.3
(evan's syndrome)
IUD INSERSI Z30.1
Iud insitu Z97.5
IUGR(Intra uterine Growth Rate) O36.5
IVCD (Intra venctricular Conduction Delay) I45.8
IVH (Intra ventricular Hemorrhage) I61.5

Kalsifikasi plasenta (serotinus) O48

KVV / Kandidiasis Vulvovaginalis B37.3+
N77.1*
KISTA ATEROMA D23.6
KAD (Ketoacidosis Diabetic) E10-E14 poin

18
 1
KAD, DM 2 E11.1
Ketoacidosis diabeticum E14.1
KEP (Kekurangan Energi Protein) E46
KKP (Kekurangan Kalori Protein) E77.8
kejang partial komplek G40.2
KISTA ORBITAL H05.8
KSH (Kataract Senile Hypermature) H25.2
KSM (Kataract Senile Matur) H25.8
KSKP (katarak sub kapsuler posterior) H26.9
KONTROL HRB J39.8
KISTA HEPAR/KISTA LIVER K76.8
KERATOSIS L57.0
Keratosis Seborrheic L82
KERATOSIS PILARIS L85.8
Keloid/scar hypertropic L91.0
KISTA GINJAL N28.1
KISTA OVARI N83.2
Keputihan/ flour albus N89.8
KET (Kehamilan Ectopic Terganggu) O00.1
KEHAMILAN LETSU O32.1
KEHAMILAN LETAK LINTANG O32.2
KMK (Kecil Masa Kehamilan) = IUGR O36.5
KPSW (Ketuban pecah sebelum waktunya) / O42.9
KPD
Kalsifikasi plasenta (serotinus) O48
Kista Ginjal Q61.0
KISTA DUKTUS TIROGLOSUS Q89.2
kemeutan/ pins/ paraesthesia R20.2
SPRAIN,STRAIN (KESELEO) T14.3
KONTROL GIGI Z01.2
KONTROL LAB Z01.7
KONTROL HT Z09.8
KONTROL TB Z11.1
KONTROL HEPATITIS Z11.5
KONTROL VIRAL DISEASE Z11.5
Kontrol Neoplasm Breast Z12.3
KONTROL ANEMIA Z13.0
KONTROL DM Z13.1
KONTROL ANC Z34.9
Kontrol Postpartum Z39.0
KONTROL ORTHOPEDI Z47.9
Kontrol Post Op Z48.9

19
KEMOTERAPI KANKER Z51.1
KEMOTERAPI other Z51.2
KONSULTASI GIZI Z71.3
KONTROL ASMA Z87.0/Z09.8
KONTROL DIGESTIVE/ANAL FISTULA Z87.1/Z87.8
KONTROL LUKA Z87.8

Lyphoma supra clavicle (shoulder joint) D36.7

LYMPADENITIS TB A18.2
Leptospirosis, unspecified A27.9
Lymphoma (malignant) C85.9
Lipoma D17.9
Lymphangioma D18.1
Lipoma supra clavicle (shoulder joint) D36.7
Leukopenia D70
Leukocytosis D72.8
LUMBOSACRAL ROOT DISORDER G54.4
Labyrinthitis H83.0
LAHB (left Anterior Hemiblock) I44.4
LPHB (Left Posterior Hemiblock) I44.5
LBBB ./ LEFT BUNDLE BRANCH BLOCK, UNSP I44.7
LVF (Left Ventricular Failure) I50.1
LVH (Left Ventricular Hypertrophy) I51.7
Laryngitis akut J04.0
laryngopharyngitis/ LPR J06.0
LARYNGITIS CRONIS J37.0
LPR (Laringoparingeal Reflux) / GERD K21.9
LIMPADENITIS AXILA L04.2
Lichen Planus (chronicus) simplex L28.0
lenetigo l81.4
LBP (Low Back Pain syndrome) M54.5
Lump in breast, unspecified (massa mamae) N63
LEUKORHEA N89.8
labiochzis Q36.9
LUTS (lower urinary tract symptom) R39.8
Lymphadenopathy colli R59.1
Lymphadenopathy, unspecified R59.1
LFT (Liver Function Test ) R94.5
Laceration ileum S36.4

20
 M

Myoma Uteri (Leiomyoma of uterus)/ myoma

D25.9
geburt
Malaise R53
Malnutrition E46
Malunion of fracture M84.0
MAS (Meconium Aspiration Syndrome) P24.0
MASA INTERVESICA N32.9
MASA OVARIUM N83.9
Massa Colon Ascenden D12.2
Massa intra abdomen R19.0
Massa mamae N63
Massa paru J98.4
mastitis N61
MCI (MILD COGNITIVE IMPAIRMENT) G31.8
MCNP (Multiple Cranial Nerve Palsy) G52.7
MDS (Myelodysplasia Syndrome) D46.9
MEATAL STNEOSIS N35.9
Meconium aspiration syndrome (MAS) P24.0
Meconium syndrome (MS) P76.0
Melaena/ hematosezia K92.1
Melanoma Malignant C43.9
Melanoma Malignant a.r. Toe C43.7
MELENA/hematoschezia K92.1
Meningitis G03.9
Meningitis Tuberculosis A17.0
Menometrorrhagia N92.1
Menorrhagia N92.0
Mesenteric TB A18.3
MESIODEN K00.1
Meteorismus (flatulence) R14
MGUS (Monoclonal Gammopathy Unspecified
D89.2
Significance)
MIGRAIN G43.9
MILD COGNITIVE IMPAIRMENT / MCI H93.2
MILIARIA L74.3
Mitral Stenosis I05.0
Mitral valve prolapse (MVP) I34.1
MOF (Multiorgan Failure) Q89.9

21
MS (Meconium Syndrome) P76.0
MS (Multiple Sclerosis) G35
MS-MR (Mitral Stenosis-Mitral Regurgitaion) I05.2
MS-MR-AR (aortic regurgitation) I08.0
MT/MISSING TOOTH/Anodontia K00.0
Mucocele buccal cavity (mucocele di bibir) K13.7
MULTIPEL VE T14.0
MULTIPLE CRANIAL VERVE G52.7
Mumps B26.9
MVP (Mitral Valve Prolapse) I34.1
Myalgia M79.1
Myelodysplasia syndrome (MDS) D46.9
Myelopathy Lumbal G95.9
Myoma uteri (Leiomyoma of uterus) D25.9
Myoma Uteri Intramural D25.1
Myoma uteri subserosal D25.2
MYOPIA H52.1

NASH (Non Alcohol Steato Hepatitis) K75.8

NPC (Nasopharynx Cancer) C11.9
NHL (Non-Hodgkin's Lymphoma ), unspecified C85.9
NEVUS MELANOCYTIC AR HIDUNG D22.3
Neurofibroma (Tumor saraf) D36.1
Non AIHA D59.4
Nodul Thyroid Bilateral E04.1
Nephropathy DM E14.2+/N08.3*
NPDR (Nonpoliperative Diabetic Rentinopathy) E14.3+H36.0*
Polyneuropathy dm E14.4+/G63.2*
Neuropathy G62.9
Neuritis optik H46
NONSTEMI (Non Segementasi Elevation
I21.4
Transmural Myocardial Infarction
NEURODERMATITIS L28.0
NEURALGIA M79.2
Nonunion fracture M84.1
Nephrotic Syndrome N04.9
NS (Nephritic Syndrome), unspecified N05.9
NERD (Non Esophagus Reflux Disease) N08.3
Nephrolithiasis+ Hydronephrosis+batu ureter N13.2
Nephrolithiasis, pyonephrosis, urosepsis N13.6

22
Nephrolithiasis/Batu Ginjal N20.0
Nephrolithiasis with ureterolithiasis N20.2
prostatitis unsp N41.9
NH / P59.9
NAW (Naso Antral Window) Q30.3
NYERI PINGGANG R10.2
Negleted Z62.4

Osteomyelitis M86.9
Other dermatophytoses B35.8
OE (Otitis Eksternal ) H60.9
OMSK (Otitis Media Suppurative Chronic) H66.3
OMA (Otitis Media Acute) H66.9
Other specified disorders of ear H93.8
OMI (Old myocardial Infarction) I25.2
Obstipation (constipation) K59.0
OA Genu Bilateral M17.0
OA genu unilateral M17.1
OA Genu (gonarthrosis) M17.9
OA (Osteoarthritis) M19.9
Osteomyelitis chronic M86.6
Osteomyelitis M86.9
Orchitis, with abscess N45.0
Orchitis, unspecified N45.9
oligomenorrhea N91.5
Oligohydramnios O41.0
Observasi perut kembung (newborn) P96.8
OF / HYPERPYREXIA R50.9
OEDEMA TUNGKAI R60.0
Over load (banyak cairan / edema) R60.9

Peritonsilar Infiltrat J36

Paratyphoid Fever A01.4
Peritonitis TB A18.3
PLAGUE PNEUMONIC A20.2

23
pityriasis vesicolor B36.0
PAPILOMA FEMUR D16.2
Papilogranuloma Patella dx D16.3
Papiloma gluteal D36.7
POLYP BLADER (POLIP KANDUNG kemih) D41.4
Polycythemia Vera D45
Pencytopenia Perifer D61.9
PCOS /POLYCYSTIC OVARIAN SYNDROME E28.2
PSM (Psychosomatic, Somatoform) F45.9
PSP (Progressive Supranuclear Palsy) G12.2
PARKINSON G20
Paraparesis Spastic G82.1
Paresis G83.9
Ptosis palpebrae (prosis of eyelid) H02.4
PINGUECULA H11.1
POAG (PRIMARY ANGLE OPEN GLAUCOMA) H40.1
Parese N III (parese nerve III) H49.0
PRESBYOPIA H52.4
Perforasi Ear / Perforasi Tympanum H72.9
Presbycusis (KEMUNDURAN PENDENGARAN PD
USIA LANJUT) H91.1
Pulmonary Hypertension, Primer I27.0
Pericarditis (with effusion) I31.9
PJV (Penyakit Jantung Valvular) I38
PAT (Paroxysmal Atrial Tachycardia) I47.1
PVC (Premature ventricular Contraction) I49.3
PIS Hemisphere, subcortical I61.0
PIS Intraventricular I61.5
PAD (Peripheral Artery Disease) I73.9
Phlebitis I80.9
Pharyngitis acute J02.9
Pneumonia lobaris J18.1
PNEUMONIA J18.9
PHARYNGITIS KRONIS J31.2
PANSINUSITIS J32.4
Polyp cavum duplex (polyp nasal cavity) J33.0
Polyp Nasal J33.9
PPOK,exerbasi akut J44.1
PPOK,emphysema, asthma bronchiale J44.8
PPOK (penyakit Paru Obstruktiv Kronik) J44.9

24
Pneumothorax J93.9
Pasca PSA K04.0
Pulpitis K04.0
Polyp pulpa dental K04.0
Pulpitis K04.0
PERIODONTITIS APICAL KRONIS/PAK K04.5
PERIAPICAL ABSES K04.7
Persistensi / Gingivitis chronic K05.1
Persistensi / Gingivitis chronic K05.1
Periodontitis Acute K05.2
PERIODONTITIS K05.3
Parotitis K11.2
Parotitis K11.2
Peptic Ulcer K27.9
Peptic ulcer K27.9
Polyp Gaster, polyp stomach and duodenum K31.7
Polyp gaster, polyp stomach and duodenum K31.7
PROCTITIS K62.8
Perforation of intestine (colon) K63.1
Perforation of intestine (colon) K63.1
Peritonitis pelvic (male) K65.0
Peritonitis diffuse K65.0
Peritonitis diffuse K65.0
Peritonitis pelvic (male) K65.0
Peritonitis K65.9
Peritonitis K65.9
Pancreatitis Acute K85
Pancreatitis acute K85
PSMBA (Perdarahan saluran makan bagian
K92.2
atas)/(PSCBA)
Perdarahan saluran makan bagian atas
(PSMBA) K92.2
PSCBB/PENDARAHAN SALURAN CERNA BAGIAN
BAWAH K92.2
Paronychia L03.0
Paronychia L03.0
Pyoderma L08.0
Pyoderma L08.0
PYTIRIASIS ALBA L30.5
Psoriasis vulgaris L40.0
PPG (Psoriasis Pustular Generalisata) L40.1

25
psoriasis pustular generalized / PPG L40.1
PYTIRIASIS LIKENOID L41.0
Postinflammatory hyperpigmentation L81.0
POLYARTERITIS NODUSA/PAN M30.0
PNA (Pyelonephritis Akut) N10
PNA / PYELONEPHRITIS AKUT N10
PNC (Pyelonephritis Chronic) N11.9
Pyelonephritis chronic (PNC) N11.9
Pyelonephritis, NOS N12
Pyonephrosis N13.6
PELVICALIECTASI N28.8
Phimosis N47
Peritonitis pelvic (female) acute N73.3
Peritonitis pelvic (female) chronic N73.4
Peritonitis pelvic (female) N73.5
PID (pelvic inflammatory diseased) N73.9
PEMBESARAN BARTHOLINI N75.8
PROLAPS VAGINAL N81.1
Prolapse of Uterus NOS , Uterovaginal Prolapse N81.4
Polyp of corps uteri (polyp endometrium) N84.0
POLYP VAGINA N84.2
Premenopausal syndrome N92.4
PUA (PENDARAHAN UTERUS ABNORMAL) N93.9
Postmenopausal bleeding N95.0
PP sc a.i. PER(Pre-eclampsia Ringan) O13
PP sc a.i. PEB (Pre-eclampsia Berat) O14.1
PP sc a.i. pre-eclampsia, unspecified O14.9
PP sc a.i. eclampsia O15.0
PP sc a.i. Varises vagina O22.1
PP sc a.i. breech presentation (presbo) O32.1
PP sc a.i. transverse presentation lie (letak
O32.2
lintang)
PP sc a.i. face presentation (presentasi muka) O32.3
PP sc a.i. oversize fetus (bayi besar) O33.5
PP sc a.i. hydrocephalic fetus O33.6
PP sc a.i. CPD (Cephalopelvic Disproportion) O33.9
PP sc a.i. Bekas sc O34.2
PP sc a.i. fetal distress O36.3
PP IUFD (Intrauterine Fetal Death) O36.4
PP a.i. IUGR (Intra Uterine Growth Rate) / KMK
O36.5
(kecil masa kehamilan)
PP sc a.i.KPD (Ketuban Pecah Dini) O42.9
PP a.i. Pengapuran Placenta (diseased, O43.9

26
placental)
PP sc a.i. Placenta previa totalis (PPT) O44.1
PP sc a.i. abruptio placenta (solusio plasenta) O45.9
PP sc a.i. HAP (Hemorrhage Antepartum) O46.9
Premature Contraction O47.0
PP premature O60
PP sc a.i. Gagal drip O61.9
PP sc a.i.IUH (Inertia Uteri Hypotonic) O62.2
PP a.i. prolonged labour (partus kala II tak
O63.1
maju) / partus lama
PP a.i. long labour, unspecified O63.9
PP dengan POPP (Porsiooccipito posterior
O64.0
persistence) / posisi
PP sc a.i. hemorrhage intrapartum O67.9
PP sc a.i. lilitan tali pusar (umbilical cord) O69.8
PP spontan letak kepala (Spontaneous Vertex
O80.0
Delivery)
PP spontan letak bokong (Spontaneous Breech
O80.1
Delivery)
PP spontan (Single Spontaneous Delivery),
O80.9
unspecified
PP dengan forceps O81.3
PP dengan VE (Vacuum Extractir) O81.4
PP dengan VE dan forceps O81.5
PP sc elective O82.0
PP sc emergency O82.1
pti / preterm infant P07.3
Pneumonia Newborn P23.9
Problem Feeding, Newborn P92.9
PPM (Persistent Pupillary Membrane) Q13.8
PFO (Patent Foramen Ovale) / ASD Q21.1
PDA (Patent Ductus Anteriosus) Q25.0
PS (Pulmonal Stenosis) Q25.6
Palatoschisis Q35.9
pelvic uretero junction Q62.1
Polydactyly, unspecified Q69.9
Palpitasi R00.2
Paralysis oto pernafasan (Respiratory Muscle) R06.8
PELVIC PAIN/NYERI PINGGANG R10.2
POLYURIA R35
Problem Feeding R63.3
PPD test R76.1
PERIKSA TELINGA/AUDIOMETRI Z01.1
Parotitis Z30.1
Pseudophakia Z96.1

27
 R

Renal Failure N19

Radiculopathy M54.1
Radiculopathy,HNP M51.1+G55.1*
RADIKS K04.1
RAP (Recurent Abdominal Pain) R10.4
RBBB (Right Bundle Branch Block) I45.1
RCC (Renal Cell Carcinoma) C64
RDS,HMD P22.0
Recurent abdominal pain (RAP) R10.4
Recurrent Anteior MI I22.0
Regurgitaion Mitral (MR), insufficiency mitral I34.0
REMATOID ARTHRITIS M06.8
Removal suture / Removal Dressing M06.9
Renal failure N19
Respiratory Distress Dyndrome P22.0
Respiratory Failure, newborn P28.5
Retardation mental F79
Retensio urine R33
RETINOPATHY H35.0
Retraction Papilla Mamae (rectraction of nipple) N64.5
Rhabdomyosarcoma a.r. vulva (paravaginal) C64
RHEUMATIC HEART DISEASE I09.9
RHEUMATOID ARTHRITIS/RA M06.9
Rhinitis acute J00
RHINITIS ALERGI J30.4
Rhinitis chronic J31.0
Right bundle branch block (RBBB) / nonspecific
intraventricular block I45.1
Right ventricular failure (RVF) I50.0
rm / retardasi mental F79
RM( Regurgitaion Mitral) I34.0
Roseola Infantum B08.2
ROTATOR CUFF TENDON M75.1
RVF (Right Ventricular Failure) I50.0
RVH (Right Ventricular Hypertrophy) I51.7

28
Shunt Expose T85.0
Observation for other suspected diseases and
conditions Z03.8
PSVT (proxymal supraventricular tachycardia) I47.1
SAB (Sub Archanoid Bleeding) I60.9
Salpingitis and oophoritis, unspecified N70.9
SB (Sinus Bradycardia) R00.1
SBP (Spontaneous Bacterial Peritonitis) K65.9
SCABIES B86
Scoliosis M41.9
scrofuloderma A18.4
SDH (Subdural Hemorrhagic) I62.0
Sebaceous Cyst L72.1
SEKLUSION H21.4
Senility R54
Sensorineural hearing loss (SNHL) H90.5
Sepsis A41.9
Sepsis newborn P36.9
Septic Arthritis M00.9
SEQ TB B90.9
Sequelae Stroke I69.4
Sequelae stroke infark I69.3
Sequelae Stroke PIS I69.1
SHOCK CARDIOGENIC R57.0
Shock Hypovolemic R57.1
shortness of breath (SOB) R06.0
Shoulder Hand Syndrome M89.0
SIADH/ SYNDROME OF INAPPROPRIATE ANTI
DIURETIC HORMONE E22.2
Sialoadenitis K11.2
Sialolithiasis K11.5
SIE (Stroke in Evolution) I64
Sinus Bradycardia (SB) R00.1
Sinusitis maxillary duplex J32.0
SKA (Syndrom Koronari Akut) I20.0
SLE (Systemic Lupus Erythematosus) M32.9
SN ( Syndrome Nephritic ) N04
SNA (Syndrome Nephritic Acute) N00.9
SNA / SINDROM NEFRITIK AKUT N04.9
SNHL (Sensorineural Hearing Loss) H90.5
SNNT E04.9

29
SOD (Septo Optic Dysplasia) Q04.4
Soft tisue tumor (STT) / TJL (Tumor jaringan
lunak) a.r. neck / leher/ TUMOR COLLI D21.0
SOL (Space Occupying Lession) D33.2
Solusio Plasenta/Ablatio Placenta O45.9
SOPT (Syndrome Obstructive Pasca TB) / COPD J44.9
Spondylitis TB A18.0
Spondyloarhtrosis, spondylosis M47.9
Spondylopathy M46.9
Spondylosis Lumbar M47.8
sss / sinus sick syndrome I49.5
ST (Sinus Tachicardia) R00.0
ST / STEMI I21.0
STEMI (Segmentasi Elevation Transmural
I21.3
Myocardial Infarction)
Stevens-Johnson Syndrome L51.1
Stomatitis K12.1
stomatitis aphtousa k12.0
Stress Ulcer K27.9
Stricture Ureter N13.5
Stricture urethra, unspecified N35.9
Stroke I64
STROKE INFARK I63.9
Stroke Perdarahan batang otak / brain stem I61.3
Stroke pis I61.9
STRUMA DIFFUSA E04.0
STRUMA MULTINODULAR E04.2
Struma Nodusa (unilateral), nontoxic E04.1
STT (Soft tisue tumor) / TJL (Tumor jaringan
D21.0
lunak) a.r. neck / leher
STT a.r. fascialis D21.9
Sub archanoid bleeding (SAH), SAB I60.9
Sub archanoid bleeding (SAH), SAB N13.5
Sudden deafnees, sudden idiopathic hearing
H91.2
loss
SUNBURN L55.9
SUSP. STROKE Z03.3
SUSP.FAM Z03.1
Suspect Tuberculosis Z03.0
SVT (supraventricular tachycardia) I47.1
Syncope R55
SYNDROM NEPHROTIC/ SN N04
Systemic lupus erythematosus (SLE) M32.9

30
 T

Tubal Pregnancy O00.1

Typhoid Fever A01.0
TB PARU RELAPS A15.0
TB Paru (Tuberculosis) A16.2
TB KELENJAR A18.2
TB ABDOMEN A18.3+/K93.0*
TB Tyroid A18.8+/E35.0*
TINEA CAPITIS B35.0
Tinea corporis B35.4
Tinea cruris B35.6
Tinea Versicolor B36.0
Tumor Palatum D10.3
Tumor Tonsil D10.4
Tumor Parotid D11.0
Tumor cecum D12.0
Tumor Paru (S) D14.3
Tumor femur D16.2
TUMOR RAHANG BAWAH D16.5
TUMOR SPINAL D16.6
TJL a.r. Popliteal fossa or space D21.2
Tumor Kulit Auricle D23.2
Tumor ginjal D30.0
Tumor kelenjar (lymph gland) D36.0
Tumor Intra Abdomen D36.7
TUMOR PERIANAL D48.5
tumor phyllodes / cystosarcoma phyllodes D48.6
Thalassemia D56.9
Thrombocytopenia, unspecified D69.6
Thrombocytosis essential D75.2
THD (Thyroid Herat Disease) E05.9
THD / THYROID HEART DISEASE E05.9+ I43.8*
TTH (Tension Type Headache) G44.2
TIA (Transient Ischemic Attack) G45.9
Trigeminal neuralgia/TGN G50.0
THORACIC ROOT DISORDER G54.3
Tuba catarrh AD H65.2
tuba cattarh h65.9
Tinnitus H93.1
Thrombosis I82.9

31
Tonsilitis Acute J03.9
TFA/TONSILO PHARYNGITIS AKUT J06.8
Tonsilitis chronic J35.0
TMJ / TEMPOROMANDIBULAR JOINT DISORDER K07.6
TEN (Toxic Epidermatitis Necrolysis) L51.2
TRIGER FINGER M65.3
Tubal pregnancy (KET / kehamilan ectopic
terganggu) O00.1
TTN (Transient Tachypnoea of Newborn) P22.1
TOF (Tetralogi of Falot) Q21.3
TR (Mild TR) / Tricuspid regurgitation Q22.8
TBI (Trauma Brain Injury) S06.9
Trauma Thorax, injury thorax S29.9
TRAUMA PENIS, INJURY PENIS S39.9
TEST KESUBURAN Z31.4

Union Fracture Z47.0

UAP (Unstable Angina Pectori) I20.0
UDT / UNDESCENDED TESTIS Q53.9
Ulcer peptic K27.9
ULCUS L98.4
ULCUS CRURIS L97
Ulcus Decubitus L89
Ulcus DM E14.5
Ulcus pedis, foot, lower limb L97
ULCUS PEPTIC K27.9
Ulcus pharynx J39.2
Underweight R63.4
UNDESCENDED TESTIS UNILATERAL Q53.1
Unspecified human immunodeficiency virus
[HIV] disease B24
Unstable angina pectoris (UAP) I20.0
Up IUD Z30.5
Ureterolithiasis/calculus ureter N20.1
Urethrolithiasis/calculus urethra N21.1
Urolithiasis N20.9
Urosepsis N39.0
Urticaria L50.9

32
 V

Vesicolithiasis N21.0
VAGINITIS N76.0
VAGINITIS CHRONIS N76.1
VAKSIN HEP B Z24.6
VARICELA B01.9
Varices esophagus (VE) I85.9
Varicosis I83.9
VASCULITIS I77.6
VAT (Ventricle Arthrial Tachycardia) I47.2
VB (Vertebra Basiler) M48.9
VCSS I87.1
VE T00.6
VE (Varices Esophagus) I85.9
Ventricle arthrial tachycardia (VAT) I47.2
Ventricular extrasystole (VES) I49.4
Verruca B07
Vertigo / Dizziness R42
VES (Ventricular Extrasystole) I49.3
Vesicolithiasis / Calculus Blader N21.0
Vestibulitis (ear) H83.0
Vestibulitis (nose) J34.8
VF (Ventricular Fibrillation) I49.0
VHB B16.9
Viral Infection B34.9
vitreus prolapse H43.0
VL (Vulnus Laceration) T14.1
VL a.r. Abdomen S31.8
VL a.r. Frontotemporal S01.8
VL a.r. genu (knee) S81.0
Vomitus R11
VORS H10.1
VSD (Ventricular Septal Defect) Q21.0
Vulnus laceration (VL) T14.1

33
 STANDARISASI KODE TINDAKAN YANG DIGUNAKAN

Nama Tindakan Kode ICD 9-CM

Adhesiolysis Abdominal 54.59
Adhesiolysis Appendiceal 54.59
Adhesiolysis Peritoneal 54.5
Adhesioysis of Ovary 65.8
Amputation BK (Below Knee), transtibial 84.15
Amputation of toe 84.11
Anal fFstulectomy 49.12
Anal Fistulotomy 49.11
Anoplasty 49.79
Anoscopy 49.21
Appendectomy 47.09
Aspiration genu, joint 47.09
Aplication of other cast (gips lainnya) 93.53

Biopsy Bulli (bladder) 57.34

Biopsy Duodenum 45.15
Biopsy Inguinal = Excision lymph node inguinal 40.24
Biopsy Nasal sinus (biopsy tumor cavum naso),
closed 22.11
Biopsy Nasopharynx 29.12
Biopsy of Anus 49.23
Biopsy of Auricular (biopsy ear) 18.12
Biopsy of Breast, closed 85.11
Biopsy of Breast, unspecified 85.19
Biopsy of Lymphatic 40.11
Biopsy of Mouth (malignant) 27.24
Biopsy of Ovary 65.12
Biopsy of Vein (Biopsi Vena) 38.21
Biopsy Palate (soft) 27.22
Biopsy Parotid gland (salivary gland) 26.11
Biopsy Peritoneum 54.23
Biopsy Polyp rectum (open) 48.25

34
Biopsy Rectum 48.25
Biopsy Skin and Subcutaneous Tissue 86.11
Biopsy Soft Tissue 83.21
Biopsy Testis 62.11
Biopsy Tongue (lidah) 25.01
Biopsy Tonsil 28.11
Biopsy Tumor a.r. Abdominal wall 54.22
BNO (Blass Nier Overzicht) / KUB (kidney ureter
bladder) 87.79
BNO IVP (Intra Venous Pyelography) 87.73
Businasi (Dilation of Urethra) 58.6
BW op (marsupilisasi) 64.2

Calibration Urethra 89.29

CAPD (continuous ambulatory peritonial
dialysis)
Cauterization of eyelid (mata kaki) 08.25
Check lab darah 90.5
Check Urine 91.3
Chemotherapy Cancer 99.25
Cholecystectomy 51.22
Cholecystotomy 51.03
Circumsisi 64.0
Close Reduction (maxilla) 76.73
Close Reduction (radius ulna) 79.02
Close Reduction of dislocation of hip (panggung) 79.75
Closed Reduction, GIPS hip 79.75
Closed Reduction, GIPS humerus 79.01
Colon inloop (radiography intestine) 87.65
Colonoscopy 45.23
Colonoscopy with biopsy 45.25
Colostomy, NOS 46.10
Colphorrhexis = Vaginal construction, laserasi
vagina 70.61
Complete Nephrectomy Bilateral 55.54
Complete Nephrectomy Unilateral 55.51
Control Epistaxis (Tampon Anterior) 21.01
CT-scan (Computerized tomography-scan), 88.01

35
abdomen
CT-scan (Computerized tomography-scan),
head 87.03
CT-scan Thorax 87.41
CT-scan Sinus 88.38
CTT (Chest Tube Thoracostomy) 34.04
Culture, Specimen From Bone 91.52
Culture, Specimen From Operative wound 91.72
Culture, Specimen From Skin 91.62
Curetage following delivery or abortion 69.02
Curetage for termination of pregnancy 69.01
curetage gigi/gusi/ 24.19
Curetage, unspecified (di rahim) 69.09
CWL (Caldwell-Luc) (maxillary sinusotomy) 22.39
Cystectomy, exicision cyst ovarii 65.29
Cystostomy Percutaneous 57.17
CPAP (Continuous Positive Airways Presure) 93.90

Debridement Dental 96.54

Debridement Fracture 79.60
Debridement Fracture foot 79.67
Debridement Luka / nonexcisional 86.28
Debridement Luka+Eksisi 86.22
Debridement Open Fracture Phalanges Hand 79.64
Debridement Tibia 79.66
Debulking (Excision Lesion) 86.3
Deroofing / Unroofing cyst ginjal 55.39
Disarticulation of toe 84.11
Dissection Axilla (Excision lymph node) 40.23
DPL (Diagnostic Peritonial Lavage) 54.25
Drainage Subcutaneous Tissue, skin 86.04
Dressing (ganti perban) 93.57

EKG (Electrocardiogram) 89.52

Echocardiografi 88.72
Eksisi Papilloma (eksisi subcutaneous tissue) 86.3

36
Eksisi Parotid 26.29
Eksisi Pterygium 11.3
Eksisi Pterygium with corneal graft (d'ombrain
operation) 11.32
Ekstraksi Corpal Esophagus 98.02
Ekstraksi Kuku, Removal nail 86.23
Ekstraksi Thrombosis, Incision of vessel 38.00
Ekstraksi Thrombosis, Incision of vessel 89.52
Endoscopy Esophagus 42.23
Episiotomy 73.6
ESWL (Extracorporeal Shockwave Lithotripsy)
gallbladder/bile duct 98.52
ESWL (Extracorporeal Shockwave Lithotripsy)
kidney, ureter/ bladder 98.51
Evacuation Clot (TUR BT) 57.49
Evakuasi Peritoneal 54.19
Excision Bartholin's Gland (cyst) 71.24
Excision Clavus, corn, skin 86.3
Excision Cyst Bartholin's 71.3
Excision Dermoid, orbit 16.92
Excision Dermoid, soft tissue, skin 86.3
Excision FAM (Fibroadenoma Mamae) 85.21
Excision Ganglion (hand) 82.21
Excision Ganglion (pedis) 83.31
Excision Gluteal 40.29
Excision Keloid 86.3
Excision Lesion of chest wall 34.4
Excision Luas pedis = excision skin, radical
(wide) 86.4
Excision Lymph Node 40.29
Excision Lymphadenopathy 40.29
Excision Lymphangioma 40.29
Excision Lyphoma di clavicle / klavikula 77.61
Excision Malignant neoplasm soft tissue 83.39
Excision Massa di lidah 25.1
Excision Mucocele di bibir 27.43
Excision Myoma Uterus 68.29
Excision of Bone, Femur 77.65
Excision of Cyst Thyroglossal 06.7
Excision of eyelid (mata kaki) 08.20

37
Excision of Soft Tissue 83.39
Excision of Verucca 08.22
Excision Pembuluh Darah Vena , lower limb 38.69
Excision Sebaceous Cyst (skin) 86.3
Excision Soft Tissue 83.49
Excision Tumor a.r. Abdominal wall 54.3
Excision Tumor of Auricle 18.29
Excision Tumor of Femur 77.65
Excision Vein 38.60
Excision Vein, upper limb 38.63
Excision Kista Orbital 16.59
Exploration CBD (Common Bile Duct) 51.51
Extended Pyelolithotomy 55.11
Extractil CBD (common bile duct) / removal,
calculus, common duct 51.41
Extraction Cerumen (removal cerumen) 96.52
Extraction Tooth 23.09
ECCE (Extra Capsular Cataract Extraction) 13.59

Fasciotomy 83.14
Forceps delivery (instrumental delivery) 72.9
FTSG (Full Thicknes Skin Graft) 86.63
Fungsi Ascites, Aspiration ascites 54.91
Fungsi Cellulitis Pedis + cruris (incision - abscess) 86.04
G

Gastroscopy+Biopsy 44.14
Gastroscopy 44.13

Heckting Cyst Ovary (Suture Ovary) 65.71

Heckting Rupture Perineum (after delivery) 75.69
Heckting Rupture Perineum (non obstetric) 71.71
Hecting Perforasi Usus 46.79
Hematomectomy (Other Oophorectomy ) 65.09
Hemodialisa 39.95
Hemorrhoidectomy 49.46

38
Heparinisasi (injection anticoagulant) 99.19
Herniorrhapy Ventralis 53.59
Herniorrhapy Femoral 53.29
Herniorrhapy, herniotomy, inguinal, bilateral 53.10
Herniorrhapy, herniotomy, inguinal, unilateral 53.00
HSV (Hysterectomy Per Vagina) 68.5
Hydrocelectomy Spermatic Cord 63.1
Hysterectomy Pervagina, unspecified 68.59
Hysterectomy, unspecified (myoma uteri) 68.9

Ileostomy 46.20
Immunization, unspecified 99.59
Incision (drainage) abscess retroperitoneal 54.0
Incision and drainage a.r. Submandibular space 27.0
Incision and drainage abscess bartholin's gland
(cyst) 71.22
Incision Breast Carcinoma 85.0
Incision Drainage Abscess Scrotum 61.0
Incision Drainage Auricle 18.09
Incision Drainage Gluteal Abscess 86.09
Incision Hymen, hymenotomy 70.11
Incision Nasopharynx (Pharyngotomy) 29.0
Incision of chest wall (cyst atheroma a.r. chest
wall) 34.01
Incision of Lymphatic 40.0
Incision of Perianal Abscess 49.01
incision Rectum 48.0
Incision Sebaceous Cyst 86.04
Incision Skin 86.09
Incision Soft Tissue 83.09
Inscision and drainage abscees genu (incision -
joint structure) 80.16
Insertion Chest Tube 34.04
Insertion dj stent (Ureteral Catherization) 59.8
Insertion ETT (Endotracheal Tube)
Insertion IUD 69.7
Insertion NGT (Nasogastric Tube) 96.07
Insertion of coronary stent (PCI) 36.06

39
Irigation of Sinus 22.00
Irigation of Testis 64.5
Isthmulobectomy 06.2
Incision Chalazion (mata) 08.09
IOL (Intraokuler Lens) 13.71

Labioplasty 27.54
LE (Laparotomy Exploratory) 54.11
LD Flap (Latisimus Dorsi Flap), breast 85.7
Ligation high (tinggi) / excision of varicocele and
hydrocele of spermatic cord / Palomo opertaion 63.1
Ligation pembuluh darah vena, lower limb 38.89
Ligation Vein 38.80
Ligation Vein, upper limb 38.83
Lithotripsy Kidney 56.0
Lithotripsy of Bile Duct 51.49
Lithotripsy (ultrasound fragmental)of bladder,
vesica, kandung kemih 57.0
Lithotripsy Ureter 56.0
Ligation Varicocele (ligation spermatic cord
varicocele) 63.1
Ligation and stripping of varives vein=ligation
varicocele 63.1

Manually Placenta, Manual removal of retained

placenta 75.4
Marsupialization (Destruction) testis 62.2
Mastotomy 85.0
Medical induction of labour/spontan drip 73.4
MRM (Modified Radical Mastectomy) bilateral 85.44
MRM (Modified Radical Mastectomy) unilateral 85.43
MOP (Medis Operatif Pria) / Vasectomy 63.73
MOW (Medis Operatif Wanita) / tubectomy 66.39
MRND (Modified Radical Neck Dissection) 40.40
MRND (Modified Radical Neck Dissection)
unilateral 40.41

40
Myomectomy 68.29
Manual Aid (partial breech extraction) 72.52

Nebulizer 93.94
Nephrotomy / nephrolithotomy 55.01
Nephroureterectomy 55.51
necrotomy debridement 86.22

Odontectomy 23.19
Omentectomy 54.4
Oophorectomy (ovariectomy), unilateral 65.3
Oophorectomy (ovariectomy), partial 65.29
Open Reduction of Mandibular Fracture 76.76
Operasi Milles (Abdominoperineal resection of
rectum) 48.5
Orchiectomy (unilateral) 62.3
ORIF (Open Reduction Internal Fixation) 79.30
ORIF Carpal dan Metacarpal 79.33
ORIF Femur 79.35
ORIF Humerus 79.31
ORIF Phalanges, phalanx 79.38
ORIF Phalanges, phalanx hand 79.34
ORIF Tarsal dan Metatarsal 79.37
ORIF Tibia+Fibula 79.36
Osteotomy Tibia 77.37
Other Appendectomy, unspecified 47.09
Other Craniotomy 01.24
Other Cystoscopy 57.32
Other Laparotomy, unspecified 54.19

Packing Absorbrable Hepar 97.16

Palatoplasty for cleft palate 27.62
Partial nephrectomy 55.4
Partus normal (manually assisted 73.59

41
delivery)/partus spontan
PA (Patology Anatomy) Breast 91.6
PA (Patology Anatomy) Lymph Node 90.7
PA (Patology Anatomy) Prostate 91.3
PE (Polyp Ekstirpasi) 21.31
Pemotongan dan suture usus (resection with
anastomosis) 43.6
Percutaneous Abdominal Drainage (fungsi
ascites) 54.91
Photo thorax, unspecified 87.44
Phototherapy, ultra violet 99.83
Preputiotomy (cercerusis) 64.91
Prostatectomy 60.69
PSD (Partial Salpingiectomy Dextra) 66.69
PSA (Pulpectomy saluran akar) 23.70
PPM (Permanent Pace Maker)/ alat pacu jantung 37.80
Partus Penyulit no 6 73.4

Removal Shunt Ventricular 02.43

Radical orchidectomy 62.41
Ro" lumbosacral (Radiography Lumbosacral) 87.24
Reconstruction of penis 64.44
Reconstruction penis 64.44
Reconstruction skin 86.89
Refracturisasi, osteoclasis 78.70
Refracturisasi, osteoclasis radius ulna 78.73
Release of intestine (dilation intestine / release
jeratan usus) 46.85
Release Soft tissue / Division Soft Tissue 83.19
Removal implant di jari kaki 80.08
Removal implant metacarpal 78.64
Removal implant metatarsal / tarsal 78.68
Removal of implanted devices from bone, tibia
and fibula (Angkat pen / P&S) 78.67
Removal of implanted devices from radiun and
ulna (Angkat pen / P&S) 78.63
Removal of tooth 23.19

42
Repair fracture phalanx pedis (foot) without
internal fixation 79.08
Repair rupture tendon 83.88
Repair subcutaneous / cutis 86.89
Reposisi / reduction fracture of nasal (closed) 21.71
Reposisi / reduction fracture of nasal (open) 21.72
Restoration od tooth by filling (tumpatan resin
komposit) 23.2
Resusciation cardiopulmonary (jantung paru) 99.60
Revision of amputaion stump (repair stump) 84.3
Ro" ankle joint 88.28
Ro" cervical, neck, leher 87.22
Ro" cervical, neck, leher, soft tissue 87.09
Ro" cruris (lower leg) 88.27
Ro" femur , upper limb 88.24
Ro" forearm / antebrachi (lengan bawah) 88.22
Ro" knee (lutut) 88.27
Ro" manus, hand 88.23
Ro" pedis 88.28
Ro" pelvis 88.26
Ro" Scedele (kepala) 87.09
Ro" shoulder (scapula) 88.21
Ro" thorax 87.23
Rrectoscopy / proctoscopy 48.23
Removal corpus alineum (foreign body) by
incision 86.05
Removal corpus alineum (foreign body) 98.20

Salpingectomy, unilateral 66.4

SC (Sectio Cesarean) 74.99
SC (sectio cesarean) SBU (segemen bawah
uterus) 74.1
SCTP (Sectio Cesarean Transperitoneal
Prapunda) 74.4
Sequestrectomy femur 77.05
Shunt Removal 02.43
Sistrunk (cyst duct thyroglosal) 06.7
SOB (Salpingo-oophorectomy Bilateral () 65.61

43
SOD (Salpingo-oophorectomy Dextra) 65.4
SOD ovary 65.62
SOS (Salpingo-oophorectomy Sinistra) 65.4
Splenorrhapy 41.95
Subtotal Lobectomy 06.39
Suture Laceration Ileum 46.73
Suture of skin and subcutaneous tissue
(heckting) 86.59
Suture Primer Duodenum (ulcer, perforation) 44.42
Sialolithectomy 26.99
Srotoplasty / skin flap 61.49

TBW (Tension Band Wring)

Tonsilectomy 28.2
TA (Tonsilectomy with Adenoidectomy) 28.3
Tranfusi darah (whole blood) 99.03
Transabdominal endoscopy of small instentine 45.11
Transfusi PRC 99.04
Transfusi Thrombocyte 99.05
Tubectomy 66.39
TUR BT (Trans Urethral Resection Bladder Tissue) 57.49
TURP (Trans Urethral Resection of Prostate) 60.29
TULIP (Trans Urethral Guided Laser Induced
Prostectomy) 60.21
Tutup defect dengan flap (Reconstruction Skin) 86.89
THR 81.51

Unilateral simple mastectomy of breast 85.41

Up dj stent (ureter) 97.62
Up dj stent (urethra) 97.65
Up IUD 97.71
Up suture 97.89
Urerthrotomy, external 58.0
Ureteral meatotomy 56.1

44
URS (Ureteroscopy) 56.31
Ureterotomy 56.2
Urethral meatotomy 58.1
Urethroplasty 58.49
Urethroplasty 58.49
Urethrotomy, internal (release of urethral
stricture) 58.5
USG (Ultrasonography) abdomen 88.76
USG (Ultrasonography) mamae 88.73
USG (Ultrasonography) paru 88.73
Ultrasound Fragmentation of Urinary Calculus 59.95

VE (Vacum Extraction) 72.79

Varicocelectomy 63.1
Vesicolithotomy / Sectio alta 57.19
Vitrectomy anterior 14.73

WSD (Water Seal Drainage) closed/ pungsi pleura 34.04

WSD (water Seal Drainage) open 34.09

45
DAFTAR SIMBOL YANG BERLAKU DI RSUD SMC KAB TASIKMALAYA

Simbol Keterangan

Symbol untuk jenis kelamin laki-laki

Symbol untuk jenis kelamin

+ perempuan

Symbol untuk pasien meninggal

+

Symbol fraktur
#

Symbol infuse

Symbol tranfusi

Tanda pasien hepatitis

Tanda pasien HIV

Tanda pasien alergi terhadap obat

ALERGI……
tertentu

Symbol Untuk Pembukaan (pada

proses melahirkan )

46
SINGKATAN YANG DIGUNAKAN DI RSUD SMC KAB TASIKMALAYA

Singkatan Arti
KL Kala
Taka Tangan Kanan
Taki Tangan Kiri
Dc Dower Cateter
BB Berat Badan
PB Panjang Badan
LK Lingkar Kepala
LD Lingkar Dada
As Afgar score
Th/ Therapi
Inf Infus
Inj Injeksi
IM Intra Muscular
IV Intra Vena
PP Post Partum
Osb Orang Sakit Baru
Os Orang Sakit
CM Compos Mentis
K/u Keadaan Umum
Kes Kesadaran
LB Labu
PRC Packed Red Cells
WB Whole blood
L Laki-laki
P Perempuan
KPD Ketuban Pecah Dini
KPSW Ketuban Pecah Sebelum Waktu
BL Blue Light
NGT Nasogastric tube
dsn Dot Sisa NGT
px Periksa
mami Makan minum
BLPL Boleh Pulang
T.A.K Tidak Ada Keluhan
dx Diagnose
O/ Oleh

47
Hemrut Hematologi Rutin
Ro Rontgen
GV Ganti Verban
V/V Vulva Vagina
YAD Yang akan Datang
POD Post Op Day
ODC One Day Care
ODS One Day Surgery
OGT Oral Gastric Tube
BU Bising Usus
DBN Dalam Batas Normal
Mika/Miki Miring kanan/miring kiri
STQ Status Quo
A/P Asi/Pasi
Perluk Perawatan luka
TPM Tetes Per Menit
TTV Tanda Tanda Vital
TD Tekanan darah
N Nadi
S Suhu
ST Skin Test
Mic Mikro
Mac Makro
APS Atas Permintaan Sendiri
Pinpak Pindah Paksa
Ragab Rawat Gabung
ROM Range Of Motion
VT Vaginal Toucher
Kont ut Kontraksi Uterus
TFU Tinggi Fundus Uteri
PPV Perdarahan Pervagina
BJF Bunyi Jantung Fetus
VK Verlos Kamar
KBI Kompresi Bimanual Internal
KBE Kompresi Bimanual External
TBBA Taksiran Berat Badan Anak
G Gravida ( Hamil )
P Para ( Melahirkan )
A Abortus ( Keguguran )
BO Blighted Ovum

48
KET Kehamilan Ektopik Terganggu
KE Kehamilan Ektopik
Meco Meconium
FD Fetal Distress
SMK Sesuai Masa Kehamilan

49
 SINGKATAN YANG TIDAK DIGUNAKAN DI RSUD SMC KAB
TASIKMALAYA

Singkatan Arti Salah Tafsiran Pembenaran

µg Microgram Keliru sebagai “mg” Gunakan “mcg”
BT Bedtime (waktu tidur) Keliru sebagai “BID”( dua kali Gunakan “tidur”
sehari)
Cc Sentimeter kubik Keliru sebagai “u” (unik) Gunakan “ml”
IN Intranasal Keliru sebagai “IM” atau “IV” Gunakan
“intranasal” atau
“NAS”
HS Setengah kekuatan saat Keliru sebagai pengantar Gunakan
tidur tidur “setengah
kekuatan” atau
“tidur”
IU** Unit internasional Keliru sebagai IV (intravena) Gunakan “unit”
atau 10 (sepuluh)
MS Morphine sulfat Keliru sebagai “magnesium Gunakan
MSO4 sulfat” “morphine
sulfate”
o.d or OD Sehari sekali Keliru sebagai “mata kanan” Gunakan “setiap
yang mengarah keobata hari”
cairan oral diberikan dalam
mata
OJ Jus jeruk Keliru sebagai OD atau OS Gunakan “jus
(mata kanan/kiri) jeruk”
Per os Melalui mulut,oral Keliru sebagai “OS” (mata Gunakan “PO”
kiri) melalui mulut
atau lisan
q.d.or Setiap hari Keliru sebagai Ollie hotel, Gunakan “setiap
terutama jika periode setelah hari”
“q” atau ekor dari”q” disalah
pahami sebagai “i”
q.h.s Malam menjelang tidur Keliru sebagai “QHR” atau Gunakan
setiap jam “malam”
Qn Malam atau sebelum tidur Keliru sebagai “qh” (setiap Gunakan
jam” “malam” atau
“pada waktu
tidur”
q.o.d.or Setiap hari Keliru sebagai “qd” (setiap Gunakan “setiap

50
 hari” hari”
q1d Harian Keliru sebagai q.i.d (empat Gunakan “setiap
kali sehari) hari”
q 6PM,etc. Setiapa malam pukul 6 sore Keliru karena “setiap 6 jam” Gunakan “setiap
hari di 6:00
“atau “6:00
sehari-hari”
SC,SQ sub subkutan Keliru sebagai SL Gunakan “setiap
q (sublingual), SQ keliru hari di 6:00
sebagai “5 setiap” the q”
dalam “sub q” telah keliru
sebagai “setiap” (misalnya
dosis heparin memerintahkan
“sub q 2 jam sebelum
operasi” disalahpahami
sebagai setiap 2 jam sebelum
operasi)
SSRI Sliding skala insulin reguler Keliru solusi sebagai kuat Menuraikan
iodine (lugol) menguraikan “skala (insulin)
“skala (insulin) geser” geser”
TIW 3 kali seminggu Keliru sebagai “3 kali sehari” Gunakan “3 kali
atau “dua kali dalam seminggu”
seminggu”
U or u** Unit Keliru sebagai nomor 0 atau Gunakan “unit”
4, menyebabkan overdosis
10 kali lipat atau lebih besar
(misalnya 4U dipandang
sebagai “40” atau 4u
dipandang sebagai “44”)
Keliru sebagai “cc” sehingga
dosis yang diberikan dalam
buku bukan unit (misalnya,
4u dilihat sebagai 4cc)
UD Sebagaimana diarahkan Keliru sebagai satu unit dosis Gunakan “seperti
yang diarahkan”

51
SIMBOL YANG TIDAK DIGUNAKAN DI RSUD SMC KAB TASIKMALAYA

Simbol Arti

3 Dram

X3d Selama 3 (tiga ) hari

@ Di

º Jam

& Dan

52
 DAFTAR SINGKATAN OBAT DAN PERESEPAN DI RSUD SMC KAB
TASIKMALAYA

A. DAFTAR SINGKATAN NAMA OBAT YANG DITETAPKAN DALAM

RESEP

No Nama Obat Singkatan

1 ATROPIN SULFAS SA
2 CHLORPROMAZIN CPZ
3 DEXTROMETORPAN DMP
4 DEXTROSE 40% D 40%
5 DEXTROSE 5% D 5%
6 FLUOROURASIL 5-FU
7 GLYCERYL GUAIACOLATE GG
8 HYDROCHLORTIAZIDE HCT
9 ISONIAZIDE INH
10 ISOSORBID DINITRAT ISDN
11 KALCIUM KARBONAT CaC03
12 KALSIUM LAKTAT Kalk
13 NEUROBION 5000 N 5000
14 Mg SO4 Magnesium Sulfat
15 PERHIDROL H202
16 PROPYTHIOURACYL PTU
17 PYRAZINAMIDE PZA
18 STRONGER NEO MINOPHAGEN C SNMC
19 TRIHEXYFENIDIL THP
20 METHOREXATE MTX

53
B. DAFTAR SINGKATAN ISTILAH PERESEPAN

Singkatan Kepanjangan Arti

R Recipe Ambillah
No Nomero Sejumlah
Aa Ana Masing-masing
Ad Ad Sampai
Add Adde Tambahkan
S Signa Penandaan atau aturan pakai
p.r.n pro re nata Jika diperlukan
d.d de die Setiap hari
b.d.d bis de die 2 kali sehari
t.d.d ter de die 3 kali sehari
q.d.d quarter de die 4 kali sehari
4.d.d quarter de die 4 kali sehari
5.d.d qinque de die 5 kali sehari
C Cochlear Sendok makan (15ml)
Cp Cochlear pultis Sendok bubur (8ml)
Cth Cochlear theae Sendok teh (5ml)
m.f Misce fac Campur, buatlah
pulv Pulvis Serbuk
adsper Adspersorius Tabur
d.t.d da tales dosis Berikan dengan takaran
sebanyak itu
a.c ante coenam Sebelum makan
p.c Post coenam Sesudah makan
d.c durante coenam Bersama makan
h.s hora somni Sebelum tidur malam
m Mane Pagi hari
v Vespere Sore hari
m.et.v mane et vespere Pagi dan sore
n Nocte Tengah malam
o.h omni hora Tiap jam
o.4.h omni quarta hora Tiap 4 jam
q.s quantum statis Secukupnya
aur Auris Telinga
dext Dextra Kanan
sin Sinistra Kiri
Oc.dect Oculus dexter Mata kanan

54
C. DAFTAR SINGKATAN YANG DILARANG DIGUNAKAN

Jangan Gunakan Potential Problem Gunakan

U,u (unit) Terbaca 0,atau 4 Unit
IU (International Terbaca i.v atau 10 Write “International
Unit) Unit”
(X.0 mg) Terbaca X0 mg,koma Tulis x mg
tidak terbaca
MS Bisa diartikan morphine Tulis “morphine
MSO4 sulfate atau Magnesium sulfate”
sulfate

55
PANDUAN SINGKATAN JENIS MAKANAN DAN JENIS DIET DI RSUD
SMC KAB TASIKMALAYA

PANDUAN SINGKATAN JENIS MAKANAN DAN JENIS DIET

1. JENIS MAKANAN

UNSUR SINGKATAN

Bubur BB

Tim T

Bubur Saring/ Bubur Sumsum BS

Makanan Biasa Untuk Keluarga MBUK

Makanan Lunak Gizi Seimbang MLGS

Makanan Cair MC

Makanan Cair Tanpa Susu MCTS

Bubur Bayi BB BAYI / PREDA

2. JENIS DIET

UNSUR SINGKATAN

Diet Tinggi Kalori Tinggi Protein TKTP

Diet Rendah Serat RS

Diet Diabetes Mellitus DM

Diet Rendah Protein RP

Diet Rendah Purin RPurin

Diet Jantung DJ

Diet Rendah Lemak RL

Diet Hati dan Kantung Empedu DH

Diet Rendah Kalori Rkal

Diet Rendah Garam RG

56
Diet Tinggi Serat TS

Diet Tinggi Protein Rendah Garam TPRG

57
INTERNASIONAL PHONETIC ALPHABET

ALPHABET DIBACA
A Alfa
B Bravo
C Charlie
D Delta
E Echo
F Foxtrot
G Golf
H Hotel
I India
J Juliet
K Killo
L Lima
M Mike
N November
O Oscar
P Papa
Q Quebec
R Romeo
S Sierra
T Tango
U Uniform
V Victor
W Whiskey
X Xray
Y Yankee

58
 BAB IV
DOKUMENTASI

Dokumen rekam medis yang akan di lakukan monitoring standarisasi kode

diagnosa, kode prosedur/ tindakan, definisi, simbol yang digunakan dan yang
tidak boleh digunakan, singkatan yang digunakan dan yang tidak boleh
digunakan adalah semua dokumen rekam medis pasien.

59