PANDUAN SIMBOL DAN SINGKATAN

BAB I

PENDAHULUAN

A. Latar Belakang

Rumah sakit merupakan sarana pelayanan kesehatan yang mutlak dibutuhkan

oleh segenap lapisan rnasyarakat dalam upaya peningkatan derajat kesehatan baik
individu maupun masyarakat secara keseluruhan. Untuk memenuhi kebutuhan
tersebut maka rumah sakit dituntut untuk memberikan pelayanan yang memadai dan
mnemuaskan. Rumah sakit harus mampu meningkatkan kualitas pelayanannya
termasuk diantaranya peningkatan kualitas pendokumentasian
rekam medis (Hatta, 2008).

Rekam medis merupakan salah satu bagian penting dalam membantu

pelaksanaan pemberian pelayanan kepada pasien di Rumah Sakit. Hal ini berkaitan
dengan isi rekam medis yang mencerminkan segala informasi menyangkut pasien
sebagai dasar dalam menentukan tindakan lebih lanjut dalam upaya pelayanan
maupun tindakan medis lain. Menurut Permenkes No 269/Menkes/Per/III/2008
tentang rekam medis, Rekam medis adalah berkas yang berisikan catatan dan
dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan
lain yang telah diberikan kepada pasien. Rekam medis adalah keterangan baik yang
tertulis maupun yang terekam tentang identitas, anamnesis, penentuan fisik
laboratorium, diagnosis, segala pelayanan dan tindakan medis yang diberikan kepada
pasien, dan tentang pengobatan, baik rawat inap, rawat jalan maupun
pengobatan melalui pelayanan rawat darurat.

Dalam penulisan di rekam medis, tidak hanya penulisannya yang lengkap dan
jelas, namun juga bisa menggunakan simbol dan singkatan dengan ketentuan ada
keseragaman penulisan simbol dan singkatan yang telah disepakati bersama oleh
semua pihak di Rumah Sakit.

B. Tujuan

1. Sebagai panduan dan acuan untuk petugas rekam medis dalam melakukan
penulisan simbol dan singkatan dalam rekam medis.

2. Mewujudkan penggunaan simbol dan singkatan yang tepat dan seragam.

C. Ruang Lingkup

Ruang lingkup pedoman ini meliputi:

1. Latar Belakang

2. Tujuan

3. Ruang Lingkup

4. Daftar Simbol Singkatan, dan daftar yang tidak boleh digunakan

5. Penutup
 BAB I

SINGKATAN YANG TIDAK DIGUNAKAN DI REKAM MEDIS

Daftar singkatan yang sebaiknya tiak digunakan merupakan bagian dari standar keamanan
pasien. Sangat mungkin terjadi kesalahan yang dikarenakan salah baca atau salah pengertian,
oleh karena itu singkatan-singkatan di bawah ini sebaiknya tidak digunakan, khususnya bila
ditulis tangan.

Singkatan/Dosis Maksud Salah Interpretasi Koreksi

Ekspresi
µg microgram Gunakan "mcg"
Salah interpretasi
menjadi mg
Setiap Disalah artikan Secara internasional berarti
QOD, qod, Q.O.D, q.o.d
keesokan sebagai frekuensi setiap 48 jam, sedangkan di
hari penggunaan obat Indonesia setiap 4x sehari
untuk 4x sehari (quart, quint), Sebaiknya

atau 5x sehari singkatan ini tidak digunakan

untuk mencegah salah arti

U or u Unit (s) Terbaca sebagai

nol (0) atau

empat (4) jika

digunakan untuk
10 atau yang lebih
besar (4U
"unit" dilarang disingkat
terbaca "40" atau
dan harus ditulis lengkap
4u terbaca
"unit"
sebagai
"44")
Salah baca

Angka nol setelah 1 mg menjadi 10 Untuk decimal jangan

titik decimal mg jika tanda gunakan angka 0
(1.0) titik tidak
terbaca
Disalah artikan
 Cubic dengan u (units)
cc jika tulisan tidak Sebaiknya gunakan ml
centimeter
jelas
 BAB II
SINGKATAN
INTERNASIONAL
YANG DIGUNAKAN DI REKAM
MEDIS

A - Alpha

Ab Abortus

ABC Advanced Activity of Daily Living

Abd Abdomen

AB gap Air-Bone Gap

ABI Ankle Branchial Index

ABP Angle Blade Plate

Abx Antibiotics

AC Air Conduction

AC-Joint Acromio-Clavicular Joint

ACC American College of Cardiolgy

ACD Anemia of Chonic Disoder

ACDF Anterior Corpectomi Dispektomi Fussion

ACEI Angiotensin Converting Enzyme Inhibitor

ACHD Adult Congenital Heart Disease

ACI Ace Inhibitor

ACL Anterior Cruciate Ligament

ACLS Advance Cardiac Live Support

ACR American College of Rheumatology

ACS Acute Coronary Syndrome

AD Auris Dextra

ADB Anemia Defisiensi Besi

ADD Addition

ADH Antidiuretic Hormone

ADHF Acute Decompensated Heart Failure

ADL Ativity Daily Living

ADO Amplatzer Ductal Occluder

Adre Adrenalin

Adv Advis

AE-Cast Above Elbow Cast

AED Automated External Defribilator

AF Atrial Fibrilasi

AFASS Acceptable Feasible Affordable Sustainable Safe

AFB Acid Fast Bacilli

Afl Atrial Flutter

AFO Ankle Foot Orthosis

AFP Acute Flaccid Paralysis

AGD Analisa Gas Darah

AGEP Acute General Erythema Postolosa

AGN Acute Glomerulonephritis

AHA American Heart Association

AHF Acut Heart Failure

AI Avian Influenza

AIDS Acqiured Immune Deficiency Syndrome

AIHA Auto Immune Hemolytic Anemia

AIJ Artitis Reumatoid Juvenil

AINS Anti Inflamasi Non Steroid

AI Alumunium

AK-Cast Above Knee Cast

AKI Akut Kidney Injury

AL Arteri Line

ALHA Autoimum Himolitik Anemia

ALI Acute Lung Injury

ALL Acut Lympoblastic Lukemia

ALO Acute Lung Oedeme

ALOS Average Length of Stay

ALS Advance Life Support

ALT Alanine Transferase

a.m after midnight

AMI Acut Myocardial Infarction

AML Acute Myeloblastic Leukimia

AMP Austin Moore Prosthesis

AMS Acute Mountain Sickness

AMT Adbreviated Mental Test

ANA Antibodi Atinuklear

Ao Aorta/Aortic

AP Anterior-Posterior X-ray

APCD Acquired Prptombin Complex

Deficiency

APH Ante Partum Haemorrogic

APS Angina Pectoris Stable

APTT Activted Partial Thromboplastin Time

ARB Angiotension Receptor Blocker

ARDS Adults Respiratory Dystress Syndrome

AR Aorta Regurgitation

ARF Acute Rheumatic Fever

ARI Acute Respiratory Infection

ARMD Age Relative Mascular Degeneration

ART Antiretroviral Therapy

ARV Anti Retro Viral

ARVD Arythmogenic Right Ventricle Dysplasia

AS Aorta Stenosis

ASA American Society of Anesthesiologist

ASB Assisted Spontaneous Breathing

ASD Atrial Septal Defect

ASI Addiction Severity Index

ASO Amplatzer Septal Occluder

Ass Assesment

ASSIST Alcohol Smoking and Substance Involvement Screening Test

AST Aspartate Transferase

ATL Achilles Tendon Lengthening

ATN Acute Tubular Necrosis

AUB Abnormal Uterus Bledding

AV Atrial Ventricular

AV Block Atrial Ventricular Block

AV shunt Atrial Venous Shunt

AVM Atrial Venous Malformation

AVN Artei-Vena Nervus

AVNRT Av-Node Reentrant Tachycardia

AVRT Av Reentrant Tachycardia

AX Axis

AZT Azido-Thymidine

B - Bravo

BAD Bipolar Affective Disorder

BADL Basic Activity Daily Living

BAL British anti-Lewisite

BAPWV Brachial Ankle Pulse Wave Velocity

BBBB Branch Bundle Bundle Block

Be Bronkoskopi
BC Bone Conduction

BCC Basal Cell Carsinoma

BCG Bacille Calmette-Guerin

BCVA Best Corected Visual Acuity

BDZ Benzodiazepine

Be Bronkhieetasis

BE Base Excess

BEC Bellow Elbow Cast

BEE Basal Energy Expenditure

BERA Brainstem Evoked Response

Audiometri

BGA Blood Gas Anaiisis

BIPAP Bllevel Positive Airway Pressure

BIS Bispectral Index

BK-CAST Below Knee Cast

BL Borderline Lepromatous

BLS Basic Life Support

BMA Bone MarrowAspiration

BMI Body Mass Index

BMP Bone Marrow Punctie

BMR Basal Metabolisme Rate

BMS Bare Metal Stent

BMV Baloon Mitral Valvulotomy

BNI Bladder Neck Incision

BNO Buick Nier Oversich

BNS Bladder Neck Stenosis

BO Blighted Ovum

BOA Behavioural Observational Audiometry

BOF Buick Oversich Foto

BOR Bed Occupancy Rate

BP Blood Pressure

BPH Benign Prostate Hypertropy

BPPV Benign Paroximal Position Vertigo

BPSD Behaviour and Psycholosical

Syndrome of Dementjc

BR Brige

BRAO Branch Retinal Arteri Occlusion

BrPn Broncho Pneumoni

BRVO Branch Retinal Vein Occlusion

BS Blood Sugar

BS 2 JPP Blood Sugar 2 Jam Post Prandial

 BSA Block Subarachnoid

BSM Bed Side Monitor

BSN Blood Sugar Napture

BSO Bi Salpingo Oophoritis

BT Borderline Tuberculoid

BTKV Bedah Thorax Kardio Vaskuler

BTO Bed Turn Over

BUN Blood Urea Nitrogen

BUT Break Up Time

BV Bacterial Vaginosis

BVUC Bipolar Voiding Urethra Cystoscopy

BW Birth Weight

C - Charlie

c Cylender Lens

Ca Calsium

CA Carcinoma

CABG Coronary Arterio Bypass Grafting

CAD Coronary Artery Disease

CAH Congenital Anomaly Hormonal

CAI S Complete Androgen

Insensitivity Syndrome

CAM Confusion Assesment Method

CAP Community Acquired Pneumonia

CAPD Cateter Ambulatory Peritonium Dyalisias

CBC Complete Blood Count

CBD Common Bile Duct

CBDC Chronic Bullous Diseases of Childhood

CC Cum Coreksi

CCB Calcium Channel Blockers

CCF Carotid Cavernous Fistila

CCR Continuous Complete Remission

CCS Canadian Cardiovasculr Society

CCT Cydocryo Therapy

Cd4 Limfosit-T Cd4+

CDC Center for Disease Control and

Prevention
CDD Control Diarrheal Disease

CDGP Constitusional Delay of Growth and

Puberty

CDH Congenital Dislocation of The Hip

CDR Cup and Disk Ratio

 CE Chlor Ethyl

Ceftri Ceftriaxon

CF Close Fracture

CGA Comprehensif Geriatric Assesment

CH Cirhosis Hepatis

CHD Congenital Heart Disease

CHF Congestive Heart Failure

CHL Conductive Hearing Loss

CIN Cervix Intraepithelial Neoplasia

CKD Cronic Kidney Deseases

CKMB Creatine Kinase Myocardial Band

CI Chloride

CLBBB Complate Left Bundle Branch Block

CLD Chronic Liver Disease

CLL Leukemia Limfositik Kronik

CM Compos Mentis

CML Cronic Myelocytic Leukemia

CMP Comprehensive Metabolic Panel

CMPA Cow's Milk Protein Allergy

CMS Chronic Mountain Sickness

CMV Controlled Mechanical Ventilation

CMV Cytomegalovirus

CNS Central Nervous System

CNV Choroidal New Vessel

CNVS Catholic Network of Volunteer Servises

Co Kobalt

Co2 Karbondioksida

CO Corneal Opacity

COD Cause of Death

COPD Chronic Obstructive Pulmonary Disease

Cor Coronary

COX Cyclooxigenae

CP Cereral Palsy

CPAP Continous Positif Airway Pressure

CPC Cor Pulmonary Chronic

CPCD Cor Pulmonole Cronic Decompensated

CPD Chephalopelvic Dispropotion

CPR Cardio Pulmonary Resucitation

CPK Creatine Phosphokinase

CPYLS Cost per Year Life Saved

Cr Creatinine

CRBBB Complate Right Bundle Branch Block

CR Crown

CRAO Central Retina Arteri Occlusion

CRF Chronic Renal Failure

Cros Crossmatching

CRP C-Reactive Protein

CRPS Complex Regional Pain Syndrome

C-Section Cesarean Section

CRT Cardiac Resynchronization Therapy

CRVO Central Retinal Vein Occlusion

Cs4 Cluster of Differention 4

CSCR Central Serious Chorio Retinopthy

CSE Combine Spinal Epidural

CSF Cerebralspinal Fluid

CSME Clinically Significant Mascular Edema

CST Care Support Treatment

csw Cerebral Salt Wasting Syndrome

CT Computerized Tomography

CTEV Congenital Talipes Equino Virus

Ctg Cardiotocographic

CTLSO Cervico Thoraco Lumbo Sacral Orthosis

CTR Cor Thorax Ratio

CTS Carpal Tunnel Syndrome

CT-SCAN Computed Tomography Scan

CTX Co-trimoxazole

CTZ Chemoreceptor Trigger Zone

Cu Copper

CUG Call User Group

CVA Cerebrovascular Accident

CVC Central Venous Catheter

CVD Cerebrovascular Diseases

CVI Chronic Venous Insuficiency

CVP Central Venous Pressure

CVS H D Cardiovascular Sclerotic Heart Disease

CW Crossed-Wire
CXR Chest X-ray

D - Delta

[D] Dextra

D10% Dextrosa 10%

D4t Stavudine

D5 % Dextrosa 5%

DAI Diffuse Axial

Injury

DBP Dyastolic Blood Pressure

DBPCFC Double Blind Control

Food Challenge

DC Dower Cateter

D&C Dilatation and Curettage

DCA Diagnostic Coronary Arteriografi

DCI Decompression Illness

DCM Dilated Cardio Myopathy

DCR Dacryo Cysto Rhinostomy

DD Differensial Diagnosa

DdE Dispneu d'Effort

ddl Didlanosine

DDST Denver Development Screening

Test

DDT Dichloro-
Diphenyl-
Trichloroethane

Decomp.

Cordis Decompensatio Cordis

DEC Diethylcarbamazine

DEET Diethyltoluamide

DES Drug Eluting Stent

DEXA Dexamethason

DF Dengue Fever

DFG Dermis Fat Grafi

DHF Dengue Hemorrhagic Fever

DHFR Dihydrofolate Reductase-

 Thymidylate Synthase

DHS Dynamic Hip Screw

DIC Disseminated Intravascular

Coagulation

DIH Drug Induce Hepatitis

DILATED CM Dilated Cardiomyopathy

DIP Distal Intraphalangeal Joint

 Dislokasi TMJ Dislokasi Temporo
Mandibular Joint

DKD Diabetic Kidney Disease

DM Diabetes Mellitus

DMD Dystropy Muscular Duchen

DMP Dextrometorphan

DO Drop Out

DoA Dead on Arrival

DOM Dysfungsi Organ Multiple

DOMP Ductus Omphalo Mesentrious

Persisten

DNR Do Not Resuscitate

DOT Directly Observed Therapy

DOTS Directly Observed Treatment

DPG Disphosphoglycerate

DPT Diphtheria, Pertusis,Tetanus

DR Darah Rutin

DRS Delirium Rating Scale

DRUJ Distal Radius Ulna Joint

DS Down Syndrom

DSA Diseases Syndrome Ascenden

DSD Desorder of Sex Development

DSS Dengue Shock Syndrome

dT Diphtheria Tetanus

DTaP Diphteria, Tetanus,

Acellular Pertussis

DTP Diphteria, Tetanus, Pertussis

DVT Deep Vein Thrombosis

Dx Diagnosis

DZP Diazepm

E - Echo

E Ethambutol

E Emergency

EBV Epstein-Barr virus

e/c Et Causa
ECCE Extracapsular Catarrac Extraction

ECG Elektro Cardiografi

Echo Echocardiogram

ED Eye Drop

EDC Estimated Date of Confinement

EDH Epidural Hematom

EDMD Emery Drifuss Muskular Dystropy

EDV End Diastolic Volume

EEG Electroencephalogram

EEM Eritema Multiforma Eksudativum

EF Ejection Fraction

EFV Efavirenz

EH Encephalopathy Hepatic

EIA Enzyme Immunoassays

EKG Electrocardiogram

EKN Enterokolitis Nekrotikans

Ekst Ekstremitas

ELISA Enzyme-Linked Immuno-Sorbent Assay

EMG Eletromyogram

EMLA Euthetic Mixture Local Anesthethic

EMV Eye, Motorik, Verbal

Endo Endodonsi

ENH Erithematosus Nodui Hypertropy

ENL Erythema Nodosum Leprosum

ENT Ear, Nose and Throat

EO Eye Ointment

EP Effusi Pleura

EPA Edema Pulmonal Akut

EPI WHO Expanded Program

in Immunisation

Epi Epineprin

EPO Eritropiotin

EpS Extrapyramidal Syndrome

ER Edentulous Ridge

ERCP Endoscopic Retrograde

Cholangiopancreatography

ES Electrical Stimulation

ESC European Society of Cardiology

ESR Erythrocyte Sedimentation Rate

ESV End Sistolic Volume

ESWL Extracorporeal Shock Wave Litotripsy

ET Endotracheal Tube
ETC02 End Tiddal Co2

ETEC Enterotoxigenic Escherichia Colli

ETT Endotracheal Tube

ETV Endoscopy Third Ventriculostomy

EVM Eye Verbal Motorik

EWSEC Early Warning Score for Emergency

Calling

Ex Etiologi

Exo Exodonsi

EXO Extra ksi

Exp Expired

Ext Extremitas

F - Foxtrot

F Feel

FAM Fibrom Adenoma Mammae

FC Fungtional Class

FCTC Framework Convention on Tobacco Control

FD Full Denture

FDC Fixed Drug Combinations

FDP Flexor Digitorum Profundus

FDS Flexor Digitorusin Superficial

Fe Iron

FESS Functional Endoscopic Sinus Surgery

FEV 1 Force Exspiratory Volume Detik 1

F FA Fundus Flourense Angiography

FFP Fresh Frozen Plasma

FFT Free Field Test

FP Feeding Plate

FI02 Fraction Inspired Oxygen

Fl Flacon

Flab Flabot

FNAB Fine Needle Aspiration Biopsy

FON Fracture of Nasal

FR Faktor Reumatoid

Fr Fraktur (#)

Fr. VL Fracture Vertebra Lumbalis

Fr. Zic Fraktur Zigomatikus

FS Frozen Shoulder
FSH Follicle Stimulating Hormone

FSME Formaldehyde Inactivated Purified Whole

Virus

FT Fisioterapi

Ft3 Free Trildoteroxin

Ft4 Free Tyroxin

FTA Fluorescent Treponemal Antigen

FTC Emtricitbine

FTSG Full Thicknes Skin Graft

FTT Failure to Thrive

FUO Fever Unknown Origin

FVC Force Vital Capacity

FWB Full Weight Bearing

Fx Fungsional diagnosis

G - Golf

G Gauge

G Gravida

G6PD Glucose 6 Phospate Dehydrogenase

GA Gout Arthritis

GAD General Anxiety Disorder

GAS Group A Streptococcus

GAVI Global Alliance for Vacines an

Immunization

GBS Gueilain Barre Syndrom

GC Neisseria Gonorrhea

GCS Glasgow Coma Scale

GDPP Gonadotropin Dependen Precocious

Puberty

GDR Gross Death Rate

GDS Geriatric Depression Scale

GE Gastro Enteritis

GEA Gastroenteritis Acute

GEFS General Epilepsy Febrile Seasure

GERD Gastroesophageal Feflux Disease

GHP Gastropathy Hipertensi Portal

Gl Gastrointestinal

GIC Glassionomer Cement

GIST Gastro Intestinal Stromal Tumor

GLN Glomerulonephritis

GMK Gingivitis Marginalis Kronis

GN Glomerulo Nephritis

Go Gonorrhea

Gr Gram
GTT Glucose Tolerance Test

GU Genitourinary

H - Hotel

H Isoniazid

H1 N1 Flu Babl

H202 3% Hlrogen Peroksla 3%

H5 N1 Flu Burung

H&H Hemoglobin and Hematocrit

H2 blocker Histamine 2 Receptor Blocker

HAART Highly Active Anti Retroviral Treatment

HACE High Altitude Cerebral Edema

HACEK Haemophylus Actinobasilus

Cardiobacterium Eikenella Kingella

HAK Hiperplasia Adrenal Kongenital

HAP Hospital Aquired Pnemonia

HAPE High Altitude Pulmonary Edema

HAPH High Altitude Pulmonary Hypertension

HB Head Box

Hb Hemoglobin

HBAIc Glycocylate Hemoglobin

HBM Health Belief Model

HBO Hiperbaric Oxygen

HBV Hepatitis B Virus

HC Home Care

HCAP Health Care Associated Pneumonia

HCC Hepatocelluler Carcinoma

HCG Human Chorionic Gonadotropin

Hcl Hydrochloric Acid

HCM Hyperthropic Cardiomyopathy

HC03 Bicarbonate

HCS Hemoglobin Color Scale

Hct Hematrocrit

HCV Hepatitis C Virus

HCW Healthcare Worker

Hd Haemodialysis

HDCV Human Diploid Cell Rabies Vaccine

HDL High Density Lipoprotein

 HDN Haemorrhagic Deseases of the Newborn

HEENT Head, Eyes, Ears, Nose and Throat

HEG Hyperemesis Gravidarum

HELLP Hemolysis, Elevated Liver Test, Low Platelets

HEM High Energy Milk

HF Hemorrhagic Fever

HFMD Hand Foot Mouth Disease

HFRS Hemorrhagic Fever with Renal Syndrome

Hg Hydrargyrum

HgbAI Hemoglobin A1C Level

HHD Hipertensive Heart Deseases

HHF Hipertensi Heart Failure

HHS Hiperosmoler Hipergilkemik State

HI Head Injury

HIE Hipoxic Ishkhemic Encephalopaty

HIL Hernia Inguinalis Lateralis

HIM Hernia Inguinalis Medial

HIPERK Hyperkalemia

HIPER Na Hypernatremia

HIPO K Hypokalemia

HIPO NA Hyponatremia

HIV Human Immunodeficiency Virus

HK Hipotiroid Kongenital

HKAFO Hip Knee Ankle Foot Orthosis

HL Hodgkin Lymphoma

HLA Human Leukocyte Antigen

HMD Hyaline Membran Deseases

HP Helicobacter Pylori

HPpEF Heart Failure Preserved Ejection Fraction

HNP Herniated Nucleous Pulposus

Hr Hour(s)

HOCm Hypertrophic Obstructive Cardiomyopathy

HP Hyperplasia Prostate

HPF High Power Field

HPI Hypopygmentasi Paska Inflammasi

HPP Haemorrhagic Post Partum

HPV Human Papilloma Virus

HR Heart Rate

Hsg Hysterosalplngography

HSP Henoch Schonlain Purpura

HGSIL High Grade Squamous Intraepithelial Lession
HRS Hepato Renal Syndrome

HSV Herpes Simplex Virus

HT Hypertension

Ht Hematocrit

HTC HIV Testing and Counseling

HTIG Human Tetanus Immune Globulin
HTLV Human T-cell Lymphotropic Virus
HUS

Hemolitic Uremic Syndrome

I - India

i Impaksi
i.m Intra Muskular

i. v Intra Vena l&D

Incision and Drainage l&O Intake
and Output (A
Interaural Attenuation

IAAS International Agranulocytosisand

Aplastic Anemia Stuy

IABP Intra Aortic Ballon Pump

IADL Instrumental Daily Living

IARC International Agency for Research on Cancer

IBD Inflamatory Bowel Disease

IBS Irritable Bowel Syndrome

i.c intra cutan

ICB Intra Cranial Bleedding

ICCU Intensive Cadiac Care Unit

ICD International Classification of Deseases

ICH Intra Cranial Haemorrhagi

ICP Intra Cranial Pressure

ICS Inter Costal Space

ICU Intensive Care Unit

ICVP International Certificate of Vactinatlon

or Prophylaxis

Id Intradermal

IDU Injection Drug Use

IDDM Insulin Dependent Diabetes Mellitus

IDK Internal Derangement of the Knee

IDW Interdental Wiring

IE Infective Endocarditis

IFA Immunofluorescence Assay

IGTT Intravenous Glucose Tolerance Test

IHD Iskhemic Heart Diseases

IHSS Idiopathic Hypertrophy Subaortic Stenosis

ILA Intratecal Labor Analgesia

ILBBB Incomplate Left Bundle Branch Block

IM Intramuscular

IMCI Integrated Management of Childhood Illness

IMF Inter Maxiliary Fixatie

INR International Normalized Ratio

10 Intra Oral

IOM Intra Opeerative Monitoring

IOL Intraocular Lens

IP Intraocular Pressure

IP Joint Inter Phalank Joint

IPAH Idiophatic Pulmonary Artery Hypertensi

IPPV Intermitten Positive Pressure Ventilation

IPSS International Prostate Symptom Score

IR Intra Red

IRBBB Incomplate Right Bundle Branch Block

IRIS Immune Reconstitution

Inflammatory Syndrome

IRRB Institutional Research Review Board

ISDN SL Isosorbide Dinitrate Sublingual

ISH Isolated Systolic Hypertension

IT Intra Thecal

ITN Insecticide-Treated Bed Nets'

ITP Idiopathic Thrombocytopenic Purpura

IU International Unit

IUD Intra Uterine Device

IUFD Intra Uterine Fetal Death

IUGR Intra Uterine Growth Restriction

IV Intravenous

IVH Intra Ventricular Haemorrhagie

IVIG Imunoglobulin Intravena

IVP Intravenous Pyelogram

IVTA Intra Vitreal

Triamcinolone Acctonide
IWL Insensible Water Lose

J - Juliet

JBE Japanese B Enchephalitis

JCML Juvenile Chronic
Myeloid Leukemia

JNC Joint National Commitee

JRA Juvenile Rheumatoid Arthritis

JVP Jugular Venous Pressure

K - Kilo

K/ Klien

KALMET Kalmetrason

KAFO Knee Ankle

Foot Orthosis

Kcl Potassium Chloride

KMC Kangoroo Mother Care

KOH Potassium Hydroxide

KP Koch Pulmonum

KPI Key Performance

Indicator

KS Keratotis Sebarroic

KV Kardiovaskuler

L - Lima

LA Lokal Anesthesi

Lab Laborat

LABC Large Area Breast Cancer

LAC Long Arm Cast

LAD Left Anterior Descending (arteri)

LAFB Left Anterior Fascicular Block

LAH Left Anterior Hemiblock

lat. Lateral

LBBB Left Bundle Branch Block

LBP Low Back Pain

LBW Low Birth Weight

LC Liver Cirrhosis

LCA Left Coronary Arteri

LCL Lateral Collateral Ligament

LCS Liquor Cerebro Spinalis

LCX Left Circumflex Arteri

LD Looding Dose

LDH Lactate Dehydrogenase

LDL Low Density Lipoprotein

 LE Laparatomy Eksplorasi

LEEP Loop Electrosurgical

Excision Prosedure

LFT Liver Function Test

LG E Lineal Gingival Erythema

LGL locun Ganong Levine

LCV Lymphogranuloma Venereum

LHF Left Heart Failure

LIH Left Inguinal Hernia

LIP Lymphocytic Interstitial Pneumonitis

LL Lepromatous

LLA Leukemia Limfobiastik Akut

LLC Long Leg Cast

LLD Leg Length Discrepency

LLQ Lower Left Quadrant

LLSB Left Lower Sternal Border

LM Lymphoma Malignant

LMA Langyngeal Mask Airway

LMNH Lymphoma Malignant Non

Hodgkin

LMP Last Menstrual Period

LMWH Low Molecular Wiight Heparin

LNH Lymphoma Non Hodgkin

LNLA Leukemia Non-Limfobiastik Akut

LOS Length of Stay

LP Lumbar Puncture

LPB Lymphadenectomy Pelvic Bilateral

LPF Low Power Field

LPFB Left Posterior Fascicular Block

LPM Liter Per Minute

LPR Laryngo Pharyngeal Reflux

LPS Linea Para Sternal

LPSB Left Para Sternal Border

LPV/r Lopinavir Boosted Ritonavir

LQTS Long Qt Syndrome

LR Lactated Ringer's Solution

LSC Lichen Simplex Chronic

LT Light Terapi

LT/PT Lumbal Tractie/ Traksi Pinggang

LUTS Long Urinary Tract Syndrome

LV Left Ventricle

LV Angio Left Ventricular Angiografi

LVE Left Ventricle Enlargement

LVEF Left Ventricular Ejection Fraction

LVH Left Ventricular Hypertrophy

M - Mike

MABP Mean Arterial Blood Pressure

MAC Mycobacterium Avium Complex

MAM Myopa Astigmat Mixtus

MAP Mean Arterial Pressure

MAS Myopa Astigmat Simpleks

MAS-MAC Myopa Astigmat Simpleks-M.A.

Compositium

MAT Multifocal Atrial Tachycrdia

MB Multibaciliary

MBC Minimum Bacterial Concentration

MC Medical Certivicate
MCH Maternal-Child Health

MCI Mail Cognitive Impairment

MCI Myocard Infark

MCL Medical Collaterial Ligament

MCL Midclavicular Line

MCNP Multiple Cranial Nerve Palsy

MCP joint Metacarpal Phalangeal Joint

MCT Medium Chain Trygliserida

MCV Mean Cell Volume

MDR Multidrug Resistant

MDS Myelo Dysplastic Syndrome

MDT Multidrug Therapy

ME Meningo Encephalitis

MED Micro Endoscopic Discectomy

METS Metabolic Equivalent

mEq millieguivalent
MF Mummifikasi

Mg Magnesium

MG Myastenia Gravis
Mgm milligram

Mgm% milligram percent

MgS04 Magnesium Sulfat

MGUS Monoclonal Gammopathy Unspecified

Syndroma

MH Morbus Hansen

MHC Major Histocompatibility Complex

MHL Mixed Hearing Loss

MI Myocardial Infarction

Ml/M R Mitral Insufisiensi/ Mitral Regurgitation

MIC Minimum Inhibitory Concentration

mL milliliter

MM Multiple Mieloma

mmHg millimeters of Mercury

MMPI The Minnesota Multiphasic Personality

Inventory

MMR Measles, Mumps, Rubella Vaccine

MMS Moh's Microghafhise Surgery

MMSE Mini Metal State Examination

MMT Methadone Maintenance Therapy

MNA Mini Nutritional Assesment

MND Motor Neuron Disease

MNT Multiple Nodule Thyroid

MODS Multiple Organ Dysfungsional Syndrome

MOEWS Modified Obstetry Early Warning Score

MOI Mechanism Of Injury

MP Metacarpal Phalangeal Joint

MPD Mieloprohfertive Desiase

MR Medical Record

MRA Magnetic Resonance Angiography

MRI Magnetic Resonance Imaging

MRM Modified Radial Mastextomy

M RSA Mehticilin Résistent Staphylococcus Aureus

MS Mitral Stenosis

MSF Médecins Sans Frontières

MSI Mitral Steno Insufisiensi

MTP Metatarso-Phalangeal

Mtx Methotrexate
MTX IT Methotrexat Intratechal

MV Mitral Valve

MVA Motor Vehicle Accident

 MVD Mitral Valve Decompression

MVP Mitral Valve Prolapse

MVR Mitral Valve Replacement

N - November

N20 Nitrous Oxide

N/A Non
Applicabl
e

N/C Non
Complaints

Na Natrium

NaCI Sodium
Chloride

NAFLD Non Alcoholic Fatty Liver Disease

NAION Non Arthritis

NASH Non Alcoholic Steato Hepatitis

NATO North Atlantic Treaty Organization

NAW Naso Antral Window

NBTE Nonbacterial Thrombotic Endocaritis

NC Nasal Canule

NCH Nafas Cuping Hidung

NDR Net Death Rate

NEC Necrotizing Enterocolitis

NEWS National Early Warning Score

NG Nasogastric

NGO Nongovernment Organization

NGT Nasogastric Tube

NHL Non Hodgkin Lymphoma

NHLM Non Hodgkin Lymphoma Malignant

NIBP/NBP Non Ivasive Blood Pressure

NIDDM Non Insulin Dependent Diabetes Mellitus

NK Nasal Kanule

NM Near Miss

NNRTI Nonnucleoside Reverse Transcriptase Inhibitor

NNT Number Needed to Treat

NO Nefropati Obstruktif

NP Nekrosis Pulpa

NPA Nasopharyngeal Airway

NPDR Non Proliferative Reverse Transcriptase Inhibitor

NPEP Nonoccupational Postexposure Prophylaxis

NPH Normal Pressure Hydrocephalus

NPO Nothing by Mouth (fasting)

N RM Non Rebreating Mask

NRTI Nucleoside/ Nucleotide Reverse Transcriptase

Inhibitor

NS Normal Saline

NSAID Non Steroidal Anti-Inflammatory Drugs

NSGI Non Specific Genitalia Infection

NSH Nefrosklerosis Hipertensi

NSP Needle Sharring Program

NSR Normal Sinus Rhytm

NSTEMI Non S-T Elevasi Myocardial

Infarction NSU Non Specific Urethritis
NtRTI Nucleotide Reverse Trascripte Inhibitor

NTT Nasotracheal Tube

NVD-NVE New Vessel On Disc-New Vessel Elsewhere

NVE Ntive Valve Endocarditis
NVG Neo Vascular Glaucoma

NVP Nevirapine

NWB Non Weight Bearing

0 - Oscar

2 Oxygen

OA Osteoarthritis

OAB Over Active Bladder

OAE Oto Acoustic Emision

O&P Ova and Parasites

OBS Organic
 Brain Syndrome

OC Oral Cndidiasls

OCD Obsesive Convulsive Disordeer

OCP Oral Contraceptive Pill

OCT Optical Coherence Tomography

Odont Odontektomi

OD Over Dosis

ODC One Day Care

ODS Oculi Dextra Et Sinistra

OE Otitis Externa
Oed Oedema

OF Open fraktur

OGTT Oral Glucose Tolerance Test

Ol Osteogenesis Imperfecta

OM Otitis Media

OMA Otitis Media Acute

OMC Osteo Myelitis Chronic

OME Otitis Media with Effusion or Oral

Motor Exercises

OMi Old Myocardial Infarction

OMSK Otitis Media Supuratif Kronis

OMZ Omeprazole

OPA Oropharyngeal Airway

OPV Oral Polio Virus Vaccine

OPLL Ossifaction of The Posterior

Longitudinal Ligament

OREF Open reduksi External Fixasi

ORIF Open reduksi Internal Fixasi

ORS Oral Rehydration Therapy

Ortho Orthodonsi

OS Ocull Sinistra

OSSN Ocular Surface Squamous Neoplasis

OTC Over The Counter

OTT Orotracheal Tube

P - Papa

p Para

P/ Planning

P/S Plate Scew

PA Patologi Anatomi

PA & Lat Posterior Anterior and Lateral

PAC Premature Atrial Complex

PACG Primary Angle Closure Gloucoma

PAD Peripheral Artery Disease

PAH Pulmonary Arterial Disease

PAI Peri Appendicular Infitrat

PAOD Perifer Arteri Occlusive Disease

Pap Papanicolaou (test)

PAP Primary Atypical Pneumonia

PAT Paroxysmal Atrial Tachycardia

PB Paucibacillary

PC Pressure Control

PCAG Primary Close Angie Glaucoma

PCEA Patient Controlled Nalgesia

PCI Percutaneous Coronary Intervention

PCL Posterior Cruciate Ligament

PCMV Pressure Control Mechanic Ventilator

PcO Polycystic Ovary

PC02 Tekanan Parslal Co2

PCP Pneumocytis Carinii (jiroveci)

PCR Pneumoniapolymerase Chain Reaction

PCEC Purified Chick Embryo Cell Vaccine

PCVI Peri Corneal Vascular Injection

PD Pupil Distance

PDA Patent Ductus Arteriosus

PE Pulmonary Emboli

PEA Pulseless Electrical Activity

Pedo Pedodonsi

PEEP Positive End Ekspiration Pressure

PEM Protein Energy Malnutrition

PEP Postexposure Prophylaxis

Perio Periodonsi

PEWS Pediatri Early Warning Score

PEX Pseudo Exfollatio Syndrome

PFO Patent Foramen Ovale

PGL Persistent Generalized Lympaenopathy

pH Hydrogen Ion Concertration Action

PH Pulmonary Hypertension

PHC Primary Health Care

PHN Post Herpetic Neuralgia

PHO Provincial Health Office (Officer)

PHPV Persistent Hyperplastik Primary Viterus

PHT Pulmonal Hipertensión

PI Pulmonal Insuffisiency

PID Pelvic Inflammatory Disease

PIP Peak Inspiratory Pressure

 PITC Provider Initiated Test and Counseling

PIV Peak Inspiratory Volume

PIVAS Pharmacy Intravenous Admixture

Services

Pku Phenylketonurea

PLT Trombosit

pm post midnight

PMI Point of Maximum Impulse

PML Posterior Mitral Leaflet

PMS Pre Menstrual Synddrome

PMTCT Prevention of Mother-to-

Child Transmission

PNA Pyelonephritis Acute

PNB Peripheral Nerve Block

PND Paroxymal Nocturnal Dyspneu

PNET Primitive Neuroectodermal Tumor

PNH Paroxysmal Nocturnal Hemoglobinuria

PNL Pyelonefrolithotomy

PO per os, orally

po pemberian oral

Po2 Tekanan Parsial Oksigen

POAG Primary Open Angie Glaucoma

PONV Post Operative Nausea Vomiting

Post-Op Post Operative

PPCM Post Partum Cardiomyopathy

PPD Purified Protein Derivative

PPE Papule Pruritic Eruption

PPG Psoriasis Pustulosa Generalis

PPH Post Partum Hemorrhage

PPI Proton Pump Inhibitor

PPHN Persistent Pulmonary Hypertension of Newborn

PPLO Pleural Pneumonia Like Organism

Pprn Permanent Pacemaker

PPV Positive Predictive Value

PR Pulmonal Regurgitation

PRC Packed Red Cell

PrEP Pre-Exposure Prophylaxis

Pre-Op Preoperative

PRF Pulsed Radio Frequency

PRN Premature Rupture as Necessery

PROM Premature Rupture of Membrane Prosto
Prostodonsi prox proximal

PRP Plafiket Rich Plasma

PS Pulmonal Stenosis

P-S Plate-Screw

PSL Parasternal Line

PSM Petugas Sosial Medik

PSMV Pressure Syncronic Intermitten Mandatory

Ventilator

PSRAP Postero Sagital Ano Recto Plasty

PSVT Paroxymal Supra Ventricular Tachycardia

PT Protrombine Time

PTB Pulmonary Tuberculosis

PTCA Percutaneous Transluminal Coronary

Angioplasty

PTI Purpura Trombositcpenik Imun

PTRM Program Therapy Rumatan Methaone

PTSD Posttraumatic Stress Disorder

PTU Propiltiourasil

PUD Peptic Ulcer Disease

PUJO Plesico Uretra Juntion Obstruktive

PV Vaginal Insertion

PVC Premature Ventricular Contraction

PVD Peripheral Vascular Disease

PVE Prosthetic Valve Endocarditis

PVR Proliferatife Vitreo Retinopathy

PVRV Purified Vero Rabies Vaccine

PWB Partial Weight Bearing

Q - Quebec

QB Quick Blood

R - Romeo

R Rifampicin

RA Rheumatoid Arthritis

RAD Right Axis Deviation

RAE TUBE Ring Adair & Elwyn Tube

RAM Rapid Asessment and
Management

RBBB Right Bundle Branch Block

RBC Red Blood Cell

RCA Right Coronary Artery

RD Retinal Detachment

RDA Recommended Daily Allowance

RDS Respiratory Systress Syndrome

Resp Respirasi

RF Rheumatic Fever

RGE Refluks Gastroesofagus

RGM Risk Grading Matrix

Rh Rhesus

RHD Rheumatic Heart Disease

RIND Reversible Ischemic

Neurological Deficit

RL Ringer Laktat

RNA Rematik Non Artikuler

ROM Range Of Motion

ROP Retinopati Of Prematurity

RP Rinoskopi Posterior

RPG Retrograde Pyelografi

RPLND Retro Peritonial Lymp

Node Desectie

RPN Risk Priority Number

RR Respiratory Rate

RSI Rapid Sequence Induction

RSK Rinosinusitis Kronis

RT Rectal Toucher

RTI Ruang Terapi Intensif

RV Right Ventricle

S - Sierra

S Sinistra

SA Sulfas Atrofin
SAB Sub Arachnoid Bledding

SA BLOCK Sinus Atrial Block

SAH Sub Arachnoid Hemorrhgae

SAM Sindrom Aspirasi Mekonium

SAP Stable Angina Pectoris

 SB Scleral Buckling

SBAR Situation Background Assesment

Recomendation

SBE Subacute Bacterial Endocarditis

SBET Standby-Emergency Self Treatment

SBP Spontaneous Bacterial Peritonitis

SC Sectio Cesarean

sc subcutaneous

sec Squmous Cell Carsinoma

SCD Sudden Cardiac Death

SDH SubDural Hematoma

sec second

sect section

SGNN Syndrome Gawat Napas Neonatus

SGOT Serum Glutamic Oxaloacetic Transaminase

SGPT Serum Glutamic Piruvic Transaminase

SH Stroke Haemoragik

SHH Shock Hyperglycaemi Hyperosmose

SIADH Syndrome of Inappropriate

Antidiuretic Hormone

SICE Small Incision Cataract Extraction

SICS Small Incision Cataract Surgery

SIDA Severe Iron Deficiency Anemia

SIDS Sudden Infant Death Syndrome

SIMV Synchronzed Intermitten Mechanical

Ventilation

Sin Sinistra

SIRS Systemic Inflammatory Response Syndrome

Sistem RAA Sistem Renin Angiotensin Aldosteron

SJS Steven Johnson Syndrome

SL Spheris Lens

SLE Systemic Lupus Syndrome

SLED Sustained Low Efficiency Dialysis

SMX Sulfamethoxazole

SN Syndrome Nephrotic

SNH Stroke Non Hemorrhagic

SNHL Sensory Neural Hearing Loss

SNNT Struma Nodusa Non Toxic

SNRT Sinus Node Reentry Tachycardia

SOAP Subjective Objective Assesment Planning

SOB Short of Breath

SOL Space Occupaying Lesion

Som Somnoien

SOMI Stesno Occepito Mandíbula Immobilization

SOPT Syndroma Obstruksi Post Tuberculosis

SOS Salphingo Ophorectomy Sinistra

SP Severe Pneumonia

SPF Sun Protector Factor

SPH Stenosis Pylorus Hypertropy

SPN Solitary Pulmonary Nodule

SPT Skin Prick Tes

SQ Subcutaneously

SQV Saquinavir

SR Sinus Rytme

SS Sickle Cell

SSJ Stven Johnson's Syndrome

SSRI Selective Serotonin Reuptake Inhibitor
STATICS Scope Tube Airway Tape Introducer Connector
Suction

STD Sexually Transmitted Disease

STEMI S-T Elevation Myocardial Infarction

STSG Slit Thicknes Skin Graft

STI Sexually Transmitted Infection

STIR Serum Transferin Receptor STT

 Soft Tissue Tumor sup
superficial susp
suspension SV Stroke
Volume SVC Superior Vena Cava
SVT Supraventricular Tachicardia SWD Short Wave
Diathermi

sx symptom

T- Tango

T Tensimeter

t Themperatur

T.ax Temperature Axilla

TA Tonsiloadenoidektomi

TACI Total Anterior Circulation Infark

TAH Totai Abdominal Hysterectomy

TAHBSO Total Abdominal Hesterectomy
Bilateral Salphingo Ophorectomy

TAVB Total AV Block

TB DOTS Tuberculosis Directly Observed

Treadment Short-Course

TBA Traditional Birth Attendants

TBC Tuberculosis

TC Trombosit Cell

TCC Transisional Cell Carcinoma

Tct Trombosit Concentrat

TCD Transverso Colostomy Dextra

TDF Tenovovir

TE Tonsilektomi

TEE Trans Esophageal Echocardiography

TEN Toxic Epidermal Necrolitiz

TENS Transcutaneous Elebtrical Nerve

Stimulation

TF Thypoid Fever

TFA Tonsilo Faringitis Acute

TFK Tonsilo Faringitis Chronic

TGA Transposition of the Great Artery

THD Thyroid Heart Disease

Themp Themperatur

Th/ Terapi

THR Total Hip Replacement

TI Trachomatous Inflammation-Intense

TIA Transient Ischaemic Attack

TIK Tekanan Intra kranial

TIMI Thrombolysis in Myocardial Infarction

TIVA Total Intravenous Anesthesia

TKR Total Knee Replacement

TL Tubal Ligation

TLO Thoraco Lumbal Orthosis

TLSO Thoraco Lumbal Sacro Ortosis

Tm Tumur

TMP Trimethoprin
Tn Tuan

TOA Tuba Ovarial Abscess

TO F Tetralogy Of Fallot

TOI Turn Over Interval

TORCH Toxoplasmosis, Rubella, Cytomegalovirus
and Heroes Simplex

TPM Temporary Pace Maker

TPN Total Parenteral Nutrisi

TR Trisupid Regurgitasi

TROP T/l Troponin T/l

TRUS Transcretal Ultra Sonographi

TS Trachomatous Scarring

TSH Thyroid Stimulating Hormone

Ts p Teaspoon

TT Tetanus Toxoid

TTB Trans Thorakal Biopy

TTE Trans Thorakal Echocardiography

TTH Tension Type Headache

TTN Transient Tachypnea of Newborn

TUIP Trans Urethral Incisition of The Prostate

TU R. B Trans Urethral Resection Of The Bladder

TUR.P Trans Urethral Resection Of The Prostate

TUSP Trans Urethral Stenting Of The Prostate

TUR Trans Urethral Resection

TURP Trans Urethral Resection of Prostate

TV Tidal Volume

TW/ST Terpi Wicara/ Speech

Therapi

Tx Terapy

U - Uniform

UA Urinalysis

UAP Unstable Angina Pectoris

UCVA Un Coreccted Visual Acuity

UDD Unit Dose Dispensing

UDT Unsdescending Testisculorum

UE Upper Extremity

UGI Upper Gastrointestinal

UNICEF United Nations Children's
Fund

UO Urine Oplat

UPJ Uretero-Pelvic Junction

Ur Ureum

UR Urine Rutin
URI Upper Respiratory Tract
Infection

URM Unit Rehabilitasi Medik

URS Uretero Renoscopy

URTI Upper Respiratory Tract

Infection

USD United States dollars

USG Ultra Sonografi

USG MATA Ultra Sonografi Mata

UTI Urinary Tract Infection

UV Ultraviolet

UVC Umbilical Venous

Catheterization

UVJ Uretero-Vesical Junction

V - Victor

VA Visual Aqulty

VAR Vaksin Anti Rabies

VAS Visual Analog Scale

VC Volume Control

VCSS Vena Cava Superior Syndrome

VCT Voluntary Conseling Test

VD Vacum Drain

VDRL Venereal Disease Research

Lab

VE Varises Esophagus

VER Visum Et Repertum

VES Ventricular Extra Systole

VF Ventricular Flbrilation

VF Vocal Fremitus

VHD Ventricular Heart Disease

VIP Ventilation

Improved Performance

Vrt Vitamin

VKDB Vitamin K Deficieny Bleeding

VL Viral Load
VOD/VOS Visus Od/ Visus Os

VP Venous Pressure

VP-Shunt Ventricle Peritonium Shunting

VPC Ventricel Premature

Contraction

VPS Ventriculo Peritoneal Shunt

VSD Ventricular Septal Defect

VSP Very Severe Pneumonia

VT Ventricle Tachycardia

Vtach Ventricular
Tachycardia

VZV Varicella Zoster Virus

W-Whisky

WA Whatsapp

WB Whole Blood

WBC White Blood Cell

WFDT Worth Four Dot Test

Wh Wheezing

WHO World Health Organization

WHR Waist Hip Ratio

Wk week(s)

WPW Wolf Parkinson

White Syndrome

WRC Wasked Red Cell

WS Washting Sindroma

WSD Water Sealed Drainage

X - X-ray

x Times

x-match cross match

XDR Extensively

Drug Resistant

Z - Zero

ZDV Zidovudine

ZEP Zinc Erythrocte

Protoporphyrin

Zn Seng
ZPP Zinc Protoporphyrin

BAB III
DAFTAR SINGKATAN LOKAL
YANG DIGUNAKAN DI REKAM
MEDIS
AA Asisten Apoteker

AAM Analisis Akar Masalah

ADP Admin Pengadaan

ADIME Assesmen Diagnosis Intervensi Monitoring Evaluasi

AGA Anggota Gerak Atas

AGB Anggota Gerak Bawah

AGD Analisa Gas Darah

AI Atas Indikasi

AKG Angka Kecukupan Gizi

Alkes Alat Kesehatan

APAR Alat Pemadam Api Ringan

APD Alat Pelindung Diri

APS Atas Permintaan Sendiri

ASI Air Susu Ibu

Aumed Audit Medis

B3 Bahan Bahaya Beracun

BB Berat Badan

BBA Berat Badan Aktual

BBI Berat Badan Ideal

BBL Berat Badan Lahir

BBLB Berat Badan Lahir Besar

BBLC Berat Badan Lahir Cukup

BBLR Berat Badan Lahir Rendah

BC (IBS) Baju Celana Instalasi Bedah Sentral

BDRS Bank Darah Rumah Sakit

BH Bubur Halus

BHP Bahan Habis Pakai

Binabang Pembinaan dan Pengembangan

Binroh Bina Rohani

BK Bubur Kasar

bln Bulan

BLPL Boleh Pulang

BPH Badan Pelaksana Harian

BPJS Badan Penyelenggara Jaminan Sosial

BPJS Naker Badan Penyelenggara Jaminan Sosial

Ketenagakerjaan

BTA Bahan Tahan Asam

CB Cukup Bulan

CD Compact Disk

CDO B Cara Distribusi Obat yang Baik

CKB Cedera Kepala Berat

CKR Cedera Kepala Ringan

CKS Cedera Kepala Sedang

CPO Catatan Pemberian Obat

CPPT Catatan Perkembangan Pasien Terintegrasi

Depkes Departemen Kesehatan

DH Diet Hati

DADRS Diare Akut Dehidrasi Ringan Sedang

DADS Diare Akut Dehidrasi Sedang

DBD Demam Berdarah Dengue

Diklat Pendidikan dan Pelatihan

Dirmed Direktur Medis

Dirum Direktur Umum

Dirut Direktur Utama

DJ Diet Jantung

DJJ Denyut Jantung Janin

DKK Dinas Kesehatan Kabupaten

DKP Disporporsi Kepala Panggul

DL Darah Lengkap

DPJP Dokter Penanggung Jawab Pelayanan

DR Darah Rutin

E Energi

ESO Efek Samping Obat

FERS Formula Enteral Rumah Sakit

g gram (satuan berat)

g/dl gram/desiliter

Gasmed Gas Medis

GB Ganti Balut

GBJ Grafik Baber Johnson

GDP Gula Darah Puasa

GDPP Gula Darah Post Pradial

GDS Gula darah Sewaktu

GDT Gambaran Darah Tepi

Genset Generator Set

GT Gigi Tiruan

GV Ganti Verban
HIS Kontraksi

HK Husnul Khotimah

HP Hari Perawatan
HPHT Hari Pertama Hari Terakhir

HPL Hari Perkiraan Lahir

IAK Indikator Area Klinis

IAM Indikator Area Manajemen

IAR Informasi Analisis Rencana

IBS Instalasi Bedah Sentral

IDO Infeksi Daerah Operasi

IGD Instalasi Gawat Darurat

IKB Instalasi Kamar Bersalin

IKP Insiden Keselamatan Pasien

IKU Indikator Kerja Unit

IMT Indeks Massa Tubuh

Inf Infus

inj. Injeksi

Inpim Instruksi Pimpinan

IPAL Instalasi Pengolahan Air Limbah

IPLC Izin Pengolahan Limbah Cair

IPSRS Instalasi Pemeliharaan Sarana Rumah

Sakit

ISK Infeksi Saluran Kemih

ISPA Infeksi Saluran Pernafasan Akut

IT Informasi Teknologi

JKN Jaminan Kesehatan Nasional

JR Jasa Raharja

K/p Kalau Perlu

Kabag Kepala Bagian

KaIns Kepala Instalasi

Karu Kepala Ruang

KB Keluarga Berencana

KDK Kejang Demam Kompleks

KDRT Kekerasan Dalam Rumah

Tangga

KDS Kejang Demam Simpleks

KEK Kekurangan Energi Kronis

KEP Kekurangan Energi Protein

Kep Kepala
KERS Komite Etik Rumah Sakit

Kes Kesadaran

Kesling Kesehatan Lingkungan

Ketuban D Darah
 Ketuban J Jernih

Ketuban K Kering

Ketuban M Mekonium

Ketuban U Utuh

kg Kilogram

KH Karbohidrat

KIB Kartu Identitas Berobat

KIFL Kala Satu Fase Lama

KIS Kartu Indonesia Sehat

KK Kulit Ketuban

kkal kilokalori

KKI Konsil Kedokteran Indonesia

KLL Kecelakaan Lalu Lintas

KLPCM Ketidaklengkapan Catatan

Medis

KNC Kejadian Nyaris Cedera

KODERSI Komite Etik Rumah Sakit

Indonesia

Komed Komite Medis

KPA Ketuban Pecah Awal

KPC Kejadian Potensial Cedera

KPD Ketuban Pecah Dini

KRS Keluar Rumah Sakit

KSM Kelompok Staff Medis

KTA Kartu Tanda Anggota

KTC Kejadian Tidak Cedera

KTD Kejadian Tidak Diharapkan

KU Keadaan Umum

KWT Kwitansi

Lab Laboratorium

LAN Local Area Network

LD Lama Dirawat

LDP Lembar Data Pengaman

LED Laju Endap Darah

LILA Lingkar Lengan Atas

LK Lingkar Kepala

LLA Lingkar Lengan Atas

LPB Lapang Pandang Besar LPK
apang Pandang Kecil

lpm liter per menit

Manajer Yanjangmed Manajer Pelayanan dan Penunjang Medis
MESO Monitoring Efek Samping Obat
MIRM Manajemen Informasi dan Rekam Medis

Monev Monitoring Evaluasi

MOP Metode Operasi Pria

Mot Motorik

MOU Memorandum of Understanding

MOW Metode Operasi Wanita

MPA Masa Penugasan Awal

MPP Manajer Pelayanan Pasien MRS

Masuk Rumah Sakit

N Nadi

NB Nasi Biasa

NIK Nomor Induk Kependudukan

NL Nasi Lunak/ Nasi Lembek

Nodin Nota Dinas

NORUM Nama Obat Rupa dan Ucapan Mirip

NT Nyeri Tekan

OK Operating Kamar

Op Operasi

Obs Observasi

PAK Penyakit Akibat Kerja

PB Panjang Badan

PBL Panjang Berat Lahir

PD Pemeriksaan Dalam

PDF Pendaftaran

PEB Pre Eklamsi Berat

Penkes Penurunan Kesadaran

PER Pre Eklamsi Ringan

Perdir Peraturan Direktur

PF Pemeriksaan Fisik

PGS Pedoman Gizi Seimbang

PH Pangkat Hidrogen

PHK Pemutusan Hubungan Kerja

PIO Pelayanan Informasi Obat

PIRS Pertemuan Ilmiah Rumah Sakit

PJI Penyakit Jantung Iskemik

PKU Pembina Kesejahteraan Umat

PL Pasien Lama

PLR Plasenta Letak Rendah

PMI Palang Merah Indonesia

PMT Pemberian Makanan Tambahan

PNPK Pedoman Nasional Pelayanan Kedokteran

PO Per Oral

Poliklinik Sebutan untuk poli rawat jalan di RS

Pelayanan Obstetric Neonatus Emergency
PONEK Komprehensif

Post date Kehamilan Lewat Waktu

PPA Profesional Pemberi Asuhan

PPJA Perawat Penanggung Jawab Asuhan

PPK Panduan Praktik Klinis

PPOK Penyakit Paru Obstruktif Kronis

PPS Post Partus Spontan

PPV Perdarahan Per Vagina

Presbo Presentasi Bokong

Preskep Presentasi Kepala

Preski Presentasi Kaki

Presmuk Presentasi Muka

PRMRJ Profil Ringkas Medis Rawat Jalan

PROGNAS Program Nasional

Ps Pasien

Psg Pasang

PTM Penyakit Tidak Menular

PTO Pemantauan Terapi Obat

PTT Pergelangan Tali Pusat Terkendali

Puka Punggung Kanan

Puki Punggung Kiri

R/ Rencana

RA Rahang Atas

RAB Rancana Anggaran Belanja

Raber Rawat Bersama

Rajal/ RJ Rawat Jalan

Ranap/ RI Rawat Inap

RB Rahang Bawah

Reg Regular

Regt Register

Rev Revisi

RG Rendah Garam

RJP Resusitasi Jantung Paru

RK Rendah Kalori

RKA Rencana Kerja dan Anggaran

RKK Rincian Kewenangan Klinis

RL Rendah Lemak

RL1 - RL5 Rekapan Laporan

RM Rekam Medis

RP Rendah Protein

RPL Rencana Pulang

Rpu Rendah Purin

RS Rendah Serat

RSU Rumah Sakit Umum

RTP Rawat Tali Pusat

RUBT Ruang Udara Bertekanan Tinggi

S1 Suara Jantung 1

S2 Suara Jantung 2

SAR Serum Anti Rabies

SDE Sulit dievaluasi

SDI Sumber Daya Insani

sdm, sdt, gls, p, bh sendok makan, sendok teh, gelas, porsi, buah

SEP Surat Elegibilitas Peserta

SHRI Sensus Harian Rawat Inap

SIMAS Sinar Mas

SIMRS Sistem Informasi Manajemen Rumah Sakit

SlOp Surat Ijin Operasi

SIP Dokter Surat Izin Praktik Dokter

SIPB Surat Izin Praktik Bidan

SIPP Surat Izin Praktik Perawat

SIRS Sistem Informasi Rumah Sakit

SKD Surat Keterangan Dokter

SKM Surat Keterangan Medis

SM Sungkup Muka

SMK Sesuai Masa Kehamilan

SMNR Sungkup Muka Non Rebreathing

SMR Sungkup Muka Rebreathing

SMRS Sebelum Masuk Rumah Sakit

SN Syndrome Nefrotik

SNH Stroke Non Haemoragik

SNT Struma Non Toksik

SOAP Subyektif, Obyektif, Assesment, Planning

SOPT Sindroma Obstruksi Pasca Tb

SpAn Spesialis Anestesi

SPB Sait Perut Berulang

SPGDT Sistem Penanggulangan Gawat Darurat Terpadu

SPI Satuan Pemeriksaan Internal

SPK Surat Penugasan Klinis

SPL Surat Perintah Lembur

SPO Standar Prosedur Operasional

SPRI Surat Perintah Rawat Inap

Spt Spontan

SPV Supervisor

SSI Segmentasi Spiral

St Status

STR Surat Tanda Registrasi

Syr Sirup

Taa Tak Ada Apa-Apa

Tab Tablet

TAK Tak Ada Kelainan

TAP Tak Ada Persediaan

TB Tinggi Badan
TBK Tulis Baca Konfirmasi

TD Tekanan Darah

TDD Tidak dapat Diterapkan

TDP Tidak Dilakukan Pemeriksaan

Telp Telepon

TEPUNGSELACIPUPUT Telapak tangan, punggung tangan, sela-sela jari, kunci, putar-

putar ujung jari, putar-putar ibu jari

TGL Tanggal

TGRA Tumor Ganas Region Axilla

th Tahun

THT Telinga, Hidung, Tenggorok

TIK Tekanan Intra Kranial

TIO Tekanan Intra Oculi

TKE Total Kebutuhan Energi

TKTP Tinggi Kalori Tinggi

Protein

TM Trimester Kehamilan
TON Traumatik Optik Neuropati

TP Tinggi Protein

tpm tetes per menit

TPPRI Tempat Penerimaan Pasien Rawat

Inap

TPPRJ Tempat Penerimaan Pasien Rawat

Jalan

Ts Teman sejawat

TT Tempat Tidur

TTA Trauma Tumpul Abdomen

ttd Tanda Tangan

TTK Tenaga Teknis Kefarmasian

tts Tetes

TTV Tanda-Tanda Vital

Tubel Tugas Belajar

Tumbang Tumbuh kembang

TUTD Tidak Usah Tunggu Dokter

TUTV Tidak Usah Tunggu Visite

Tx Terapi

u/ Untuk

ue usus externus

UK Usia Kehamilan

UL Urine Lengkap

up usus propius

URT Ukuran Rumah Tangga

VTN Ventilator Tekanan Negatif

VTP Ventilator Tekanan Positif

WIB Waktu Indonesia Barat

WNA Warga Negara Asing

WUS Wanita Usia Subur

ZISWAF Zakat Infaq Shodaqoh Wakaf

 BAB IV

SIMBOL YANG DIGUNAKAN DIREKAM MEDIS

®
Norma
l

Male
o+ Female

@ at

& and

+ Plus; excess; acid reaction;

positive

- Minus; deficiency; alkali

e reaction; negative

± Pius or minus; either positive or

negative; indefinite

# Fracture

+ Divided by

X Multiplied by; magnification

= Equals

> Greater than; from which is

derived

< Less than, derived from

° Degree

% Percent
 BAB V
PENUTU
P

Demikian panduan Simbol dan Singkatan Rekam Medis ini dibuat untuk digunakan
sebagai acuan pelayanan di semua pelayanan di RS Charlie Hospital Kendal. Dengan pedoman
ini diharapkan Pelayanan di RS Charlie Hospital Kendal dapat dilaksanakan sesuai peraturan
perundang-undangan yang berlaku.

Ditetapkan di : Kendal
pada tanggal :
DIREKTUR

dr. M. Riza Setiawan,MOSH