DAFTAR SINGKATAN DIAGNOSA, TINDAKAN,

SIMBOL dan ISTILAH REKAM MEDIS

DI RSUD KABUPATEN SUMEDANG 2022

RUMAH SAKIT UMUM

DAERAH KABUPATEN
SUMEDANG TAHUN 2022
 I(ABUP N SUM ANG
PEIUTRIITTAH
MAH SAKIT UMUM DAE H SUMEDANG
Jalan Palasad I!to.8O Tetp. (O26U 2O1 1 Fax. ZO497A
Jalan Prabu Geusan UIun So. 41

SUME DAIVG 45311

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RUMAH SAITIT UMUM DA I{ABU EIII SUMEDAIIG
ItoMOR t L44 TAHUN ZOZ?
T TAISG

PEI{ PAII DA R sINe il DIAcItosA, TINDAKAN, sIMBoL

DAISISTILATI MM IS
DA RUMAH SAKIT UIIIUM DA H IIABU EIT SUMEDAfiG

. DENGAN HIIIAT TUHAIY NG MAIIA ESA

DIREKTUR RUMAII SAKIT UMUM DAERAII ST'MEDANG

hllenimhan#: a. bahwa dalam memberikan pelayanan kepada pasien semua

catatan dan tuiisan yang dibuat oleh dokter atau dokter gigi
tentang segala tindakan yang dilakukan kepada pasien
dalam rangka pemberian pelayanan kesehatan disimpan
didalam berkas Rekam Medis .;
b. bahwa clokumen/berkas Rekam Medis adalah catatan
dokter, dokter gigi, dan/atau tenaga kesehatan tertentu
laporan hasil penunjang, catatan observasi dan pengobatan
harian dan semua rekaman. baik berupa foto radiologi,
gambar pencitraan (imagi , dan rekaman elektor diagnostic
c. bahwa rekam medis harus dibuat secara tertulis, lengkap
dan jelas ; untuk memudahkan pernbacaan dan
keseragaman maka diperlukan daftar singkatan diagnosa,
istilah dan symbol yang mudah dibaca dan dipahami oieh
semua pengguna berkas rekam medis.
d. bahwa untuk mencapai maksud sebagaimana pada butir a,
b, dan c diatas, perlu ditetapkan dengan Perubahan
Keputusan Direktur Rumah Sakit Umum Daerah Kabupaten
Sumedang.
Ivlengingat : 1. Undang-Undang Republik Indonesia Nomor 65 Tahun 2005
Tentang Pedoman Penyusunan dan Penetapan Standar
Pelayanan Minimal;
Undang - Undang Nomor 29 Tahun 2AO+ tentang Praktik
Kedokter:an (Lembaran Negara Republik Indonesia Tahun
2OA4 Nomor 116, Tambahan Lembaran Negara Republik
Indonesia Nomor aa31);
S" Feraturan IVIenteri Kesehataru Nornur
269 I Menkes/ Per/ iII / 2 008 tentang Rekarn Medis ;

Peraturan Menteri Kesehatan Nomor

290/MenkeslPer/illlz008 tentang Persetujuan Tindakan
Kedokteran;
Peraturan Menteri Kesehatan Repubiik Indonesia Nomor
1 69 1 lMenkes lPer
lVIl / 2011 Tentang Keselamatan Pasien
Rumah Sakit;
Peraturan Menteri Kesehatan Nomor 12 Tahun 2O2A
tentang Akreditasi Rumah Sakit;
Keputusan Menteri Kesehatan Nomor HK.01 .07
/MENKES I 1128 / 2022 tentang Standar Akreditasi Rumah
Sakit;

MEMUTUS T{

Menetapk#,r: : KEPUTUSAN DIREKTUR RSUD KABUPATEN SUMEDANG

TENTANG PENETAPAN DAFTAR SINGKATAN DIAGNOSA,
TINDAKAN , SIMBOL DAN ISTILAH REKAM MEDIS PADA
RUMAH SAKIT UMUM DAERAH KABUPATEN SUMEDANG
KffiSATU Kebijakan Daftar Singkatan Diagnosa, Tindakan, Simbol dan
Istilah Rekam Medis sebagaimana dimaksud pada diktum
Kesatu sebagaimana dimaksud terlampir dalam lampiran
keputusan ini;
KffiT}IJA : Daftar Singkatan Diagnosa, Tindakan, Simbol dan Istilah
Rekam Medis sebagaimana dimaksud pada diktum Kesatu
merupakan acuan dan wajib dilaksanakan oleh seluruh
profesional pemberi asuhan (PPA) dalam memberikan
 pelayanan kepada pasien pada Rumah Sakit Umum Daerah
Kabupaten Sumedang;
Keti,ga Biaya yang timbul akibat dikeluarkannya keputusan ini
dibebankan pada anggaran Rumah Sakit Umum Daerah
Kabupaten Sumedang.
Keempat Keputusan ini berlaku sejak tanggal ditetapkan, dan apabila
terdapat kekeliruan dalam penetapannya akan diadakan
perbaikan sehagaimana mestinya.

ffiIT p ffi'ffiE stvmffiffiffi&ffiffi

TAffiffiGAL trS SffiFTMBfiBffiR EffiP*

ffiTREKTUR
T UMTJM MAMRAF{
SUMMDANffi

6X2 20fir12 I S05

 KATA PENGANTAR

Puji Syukur kami panjatkan kehadirat Allah SWT atas segala rahmat dan
karunia-Nya yang dilimpahkan, sehingga kami dapat menyelesaikan Daftar
Singkatan, Diagnosa, Istilah dan Simbol Rekam Medis RSUD Kabupaten
Sumedang dengan baik. Daftar Singkatan, Diagnosa, Istilah dan Simbol Rekam
Medis RSUD Kabupaten Sumedang ini sebagai acuan atau pedoman dalam
menerapkan atau menggunakan Singkatan, Diagnosa, Istilah dan Simbol
Rekam Medis di lingkungan RSUD Kabupaten Sumedang
Penulisan Daftar Singkatan, Diagnosa, Istilah dan Simbol Rekam Medis
RSUD Kabupaten Sumedang ini tidak akan diselesaikan dengan baik tanpa
adanya dukungan, bantuan dari semua pihak yang terlibat. Oleh karena itu,
pada kesempatan ini kami menyampaikan terima kasih kepada semua pihak
yang telah bekerja sama dengan baik dan telah memberikan bantuan baik moril
maupun materil dalam proses pembuatan Daftar Singkatan, Diagnosa, Istilah
dan Simbol Rekam Medis RSUD Kabupaten Sumedang ini. Semoga segala amal
kebaikan Bapak/Ibu/Saudara mendapat pahala dari Allah SWT, amin.
Akhirnya kami berharap semoga Daftar Singkatan, Diagnosa, Istilah dan
Simbol Rekam Medis RSUD Kabupaten Sumedang ini dapat memberikan
manfaat bagi kita semua, khususnya bagi Instalasi Rekam Medis untuk dapat
meningkatkan dan melaksanakan segala kegiatan dan Tupoksi, serta umumnya
bagi seluruh unit terkait di Rumah Sakit Umum Daerah Kabupaten Sumedang.

Sumedang, 01 Oktober 2022

Instalasi Rekam Medis

i
 DAFTAR ISI

Halaman
A. KATA PENGANTAR ........................................................................................i
B. DAFTAR ISI.......................................................................................................ii
1. A ....................................................................................................................1
2. B ....................................................................................................................2
3. C ....................................................................................................................3
4. D ....................................................................................................................4
5. E ....................................................................................................................5
6. F,G ................................................................................................................6
7. H....................................................................................................................7
8. I,J,K ..............................................................................................................8
9. L,M ...............................................................................................................9
10. N ....................................................................................................................10
11. O,P ................................................................................................................11
12. Q,R,S ............................................................................................................13
13. T ....................................................................................................................15
14. U,V,W ...........................................................................................................16
15. X,Y,Z ............................................................................................................17
RUANG PERAWATAN.........................................................................................17
SYMBOLS ...............................................................................................................17

ii
 DAFTAR SINGKATAN DIAGNOSA, ISTILAH DAN SIMBOL
REKAM MEDIS RSUD KABUPATEN SUMEDANG 2022

SINGKATAN PENJELASAN
No
A
1 a ante (before)
2 a/r Ad Regio
3 A&W
4 AAA Aneurisma Aorta Abdominalis
5 AAS Acute Aortic Syndrome
6 ACS Acute Coronary Syndrome
7 AB Abortus
8 AB Incomplete Abortus Incomplete
9 AB Antibiotik
10 Abd Abdomen
11 ABD Alat Bantu Dengar
12 ac ante coenam (sebelum makan)
13 AC Anterior Chamber
14 ACE
15 ACLS Advanced Cardiac Life Support
16 ACOS Asma COPD overlap syndrome
17 AD Auris Dextra
18 Ad lib sesuka bayi
19 ADH Anti Diuretic Hormone
20 ADHD Attention Deficit Higher Activity Disorder
21 ADHF Acute Decompensated Heart Failure
22 ADL Activities for Daily Living
23 Admisi pintu/ijin masuk bagi pasien
24 ADO Amplatzer Ductal Occluder
25 ADS Auris Dextra Sinistra
26 AF Atrial Fibrillasi
27 AF RVR Atrial Fibrilation Rapid Ventricular Respon
28 Aff Lepas
29 Aflutt Atrial Flutter
30 AGA Appropriate Gestational Age
31 AGN Acut Glomerulo Nefritis
32 AH Abdominal Hysterectomy
33 AHF Acute Heart Failure
34 AI Aorta Insufisiensi
35 AIDS Acquired Immuno Deficiency Syndrome
36 AIHA Auto Immune Haemolytic Anaemia
37 AK Above the Knee
38 AKA Above the Knee Amputation
39 AKI Acute Kidney Injury
40 ALI Acute Limb Ischemia
41 ALL Acute Leukemia Lymphocytic
42 ALN Anterior Lymph Node
43 ALP Acute Laringo Pharingitis
44 ALS Amyotrophic Lateral Sclerosis
45 ALT Acute Laryngitis and Tracheitis
46 AM Astigmat Mixtus
47 AMC Astigmat Myop Compositus
48 AMD Age Macular Degeneration
49 AMI Acute Myocard Infark
50 AML Acute Myeloblastic leukemia
51 AMML Acute Myelo Monocytic Leukemia
1
 52 Amp Ampul
53 AMS Astigmat Myop Symplex
54 An Anestesi
55 ANC Ante Natal Care
56 ANP Advance Nurse Practitioner
57 ANT Anterior
58 AP Angina Pectoris
59 APB Ante Partum Bleeding
60 APH Ante Partum Haemorrhage
61 APOTEK tempat pengambilan obat
62 APP Appendicitis
63 Aps Atas permintaan sendiri
64 APS Angina Pectoris Stabil
65 AR Ablation Retina
66 AR Aortic Regurgitation
67 ARA Atherosclerosis of Renal Arteholes
68 ARC AIDS Related Complex
69 ARD Acute Respiratory Disease
70 ARDS Acute Respiratory Distress Syndrome
71 ARE Ablation Retina Exudative
72 ARF Acute Rhematic Fever
73 ARF Acute Renal Failure
74 ARI Acute Respiratory Infection
75 ARMD Aged Related Macular Degeneration
76 ARR Ablation Retina Regmatogen
77 ART Ablation Retina Traksi
78 AS Aorta Stenosis
79 ASA acetyl salycylic acid / aspirin
80 ASCVD Arterio Sclerotic Cardio Vascular Disease
81 ASD Atrial Septal Defect
82 ASH Astigmatism Hypermetropic
83 ASHD Athero Sklerosis Heart Disease
84 ASI Air Susu Ibu
85 ASO Amplatzer Septal Occluder
86 ASSEMBLING Memilah berkas
87 AT Atrial Tachycardia
88 ATN Acute Tubular Necrosis
89 AUB Abnormal Uterin Bleeding
90 Aus© auscultation
91 AV Acne Vulgaris
92 AV Arteriovenosus
93 A-V BLOCK Atrio-Ventricular Block
94 AV blok 1-3 Atrioventricular Blok 1-3
95 AVM Arterio Venous Malformation
96 AVNRT Atrioventricular Nodal Reentrant Tachycardia
97 Avr Aortic Valve repair
98 AVR Aortic Valve Replacement
99 AVRT Atrioventricular Reentrant Tachycardia
100 AVSD Atrioventricular Septal Defect
101 AWO Antrostomi Wash Out
102 Ax/ Anamnesa
B
103 B/G Bentuk dan Gerak
104 B/O Because of
105 BAB Buang Air Besar
106 BAK Buang Air Kecil
107 BAS Ballon Atrial Septostomy
108 BB Berat Badan
2
109 BB/TB Berat Badan berdasarkan Tinggi Badan
110 BB/PB Berat Badan berdasarkan Panjang Badan
111 BB/U Berat Badan berdasarkan Umur
112 BBLR Berat Badan Lahir Rendah
113 BCC Basal Cell Carcinoma
114 BCG Bacillus Cucmetze Guerin
115 BG Bone graf
116 Bid twice daily
117 Bil(at) bilateral
118 BK below knee
119 BKA below the knee amputation
120 BLE Both Lower Extremities
121 BLPL Boleh Pulang
122 BM Bone Marrow
123 BMS Bare Metal Stent
124 BMV Ballon Mitral Valvuloplasty
125 BNO Blaas Nier Cvemicht
126 BO Blight Ovum
127 Bol bolus
128 BOR Bed Occupancy Rate
129 BP Bells Palsy
130 BPH Benign Prostat Hypertrofi
131 BPJS Badan Penyelenggara Jaminan Sosial
132 bpm breaths or beats per minute
133 BPPV Benign Paroxysmal Positional Vertigo
134 BR Bed Rest
135 BRAO Branch Retinal Arterial Occlusion
136 BRM Berkas Rekam Medis
137 Bronch bronchoscopy
138 BRPN Bronchopneumonia
139 BRVO Branch Retinal Vein Occlusion
140 BS blood sugar
141 BSA Body surface area
142 BTO Bed Turn Over
143 BU Bising Usus
144 BW Buta Warna
C
145 C/P Cor dan Pulmo
146 CA Carcinoma
147 CA CN Carcinoma Cavum Nasal
148 CAB Coronary Artery Bypass
149 CABG Coronary Artery Bypass Graft
150 CAD Coronary Artery Disease
151 CAL Calculnus
152 CAP Community Acquired Pneumonia
153 CAPD Continuosous Ambulatory Peritoneal Dialysis
154 CAPS Capsule
155 CAS Carotid Artery Stenosis
156 CAT Computerized Axial Tomography
157 Cath catheter
158 CAVSD Complete Atrio- Ventricular Septal Defect
159 CC Common Cold
160 CCLI Critical Chronic Limb Ischemia
161 CCS Fc I-IV Canadian Cardiovascular Socieaty Function Class I-IV
162 CCU Cardiac Care Unit
163 CE Cerebral Embolism
164 CEU Continuing Education Unit
165 CH Cirosis Hepatis
3
166 CHB Complete Heart Block
167 CHD Congenital Heart Disease
168 CHF Congestive Heart Failure
169 CHL Conductive Hearing Loss
170 CI Cardiac Insufficiency
171 CICU Cardiac Intensive Care Unit
172 CKD Chronic Kidney Disease
173 CLD Chronic Liver Disease
174 CLI Chronic Limb Ischemia
175 CLL Chronic Lymphocytic Leukemia
176 CMD Cyto Megalo inclusion Disease
177 CML Chronic Myelocytis Leukemia
178 CN Cavum nasi
179 CO Cardiac Out put
180 COMCER Commotion Cerebri
181 COPD Chronic Obstructive Pulmonary Disease
182 CORPAL corpus allineum
183 CP Cerebral Palsy
184 CPAP Continuous Positive Airway Pressure
185 CPD Cephalopelvic Disproportion
186 CPG Clopidogrel
187 CPP Cerebral Perfusion Pressure (tekanan perfusi serebral)
188 CRAO Central Retinal Arterial Occlution
189 CRF Cronic Renal Filure
190 CRS tipe 1-5 Cardio Renal Syndrome Type 1-5
191 CRT Cardiac Resynchroninzation Therapy
192 CRVO Central Retinal Vein Occlusion
193 CSC Central Serrous Chorioretinopathy
194 CSF Cerebrospinal fluid
195 CSSD Central Sterilisasi Suplay Departement
196 CT SCAN Computed Tomography Scanning
197 CTEV Congenital Talipas Equino Varus
198 CTH Cochlear Theae
199 CTS Carpal Tunnel Syndrome
200 CVA Cerebro Vascular Accident
201 CVD Cardio vascular disease
202 CVI Chronic Venous Insufficiency
203 CVP Central Venous Presure (tekanan vena sentral)
204 CXR Chet x-ray
D
205 D/C Discharge (unacceptable abbreviation)
206 DAT Diet As Tolerated
207 DB Dog Bite
208 DBN Dalam Batas Normal
209 DC Decompensatio Cordis
210 DCFC Decompensation Cordis Functional Class
211 DCM Dilated Cardiomyopaty
212 DD Differential Diagnosis
213 DDS Diphenil Dietil Sulfon
214 DECUB Decubitus Ulcer
215 DES Drug Eluting stent
216 DF Dengue Fever
217 DHF Dengue Haemorrhagic Fever
218 DIC Disseminated Intravascular Coagulation
219 DILI Drug Induced liver Injury
220 DJJ Denyut Jantung Janin
221 DKA Dermatitis Kontak Alergi
222 DKD Diabetic Kidney Disease
4
223 DKI Dermatitis Kontak Irritant
224 DKM Disfungsi Kelenjar Meibom
225 DM Diabetes Mellitus
226 DM T1 Diabetes Mellitus type 1 (IDDM)
227 DMT2 Diabetes Mellitus type 2 (NIDDM)
228 DNI Do Not Intubate (jangan intubasi)
229 DNR Do not resucitate
230 DOA Death on arrival
231 DOB Date of birth
232 DOCF Development Odontogenic Cyst Follicullar
233 DOE Dyspnoe of Effort
234 DON Director of nurses
235 DP Disharge Planning
236 DPJP Dokter Penanggung Jawab Pasien
237 DPK Defisiensi Protein Kalori
238 DPL Darah Perifer Lengkap
239 DRG Diagnosis Related Group
240 DSM Diagnostic and Statistical Manual of mental disorders
241 DSS Dengue Shock Syndrome
242 DT Delirium Tremens
243 DUB Dysfunctional Uterine Bleeding
244 DVR Double Valve Replacement
245 DVT Deep Vein Thrombosis
246 DW Destilled water
247 Dx Diagnosis
E
248 E/ Etiology
249 EBD Epidemolisis Bulosa Distrofik
250 EBL estimated blood loss
251 E coli Escherichia coli
252 E.C Electro Cauterisasi
253 ec Et. Causa
254 Ec enteric coated
255 ECCE Extra Capsular Cataract Extraction
256 ECD Endocardial Septal Defect
257 ECF Extended Care Facility
258 ECG Elektro Cardio Grafi
259 Echo Echocardiogram
260 ECMO Extra Corporeal Membrane Oxygenation
261 ECV Extra Cellular Volume
262 ECW Extra Cellular Water
263 ED Eye Drops
264 EDC Estimated Date of Confinement
265 Edent Edentulous
266 EDH Epidural Hematome
267 EEG Electro Encephalogram
268 EENT Eye, Ear, Nose, Throat
269 EEP End Expiratory Pressure
270 EF Ejection Fraction
271 EFA essential fatty acid
272 Eff PER Efusiperikard
273 EFLO Efloresensi
274 EGA Estimated Gestational Age
275 EKG Elektro Kardio Gram
276 ELISA Enzyme Linked Immunosorbent Assay
277 EMG Elektro Myelo Grafi
278 EN Enteral Nutrition
279 ENT Ear, Nose, Throat
5
280 EO Eye Ointment
281 EOMB Explanation Of Medical Benefits
282 EP Epilepsi
283 EPAP Expiratory Positive Air Way Pressure
284 EPI Epinephrine
285 EPO Erythropoetin
286 EPS Extra Pyramidal Symptoms
287 ERACS Enhanced Recovery After Cesarean Surgery
288 ERS Early Repolarization Syndrome
289 ESLD End Stage Liver Disease
290 ESRD End Stage Renal Disease
291 ET Endotracheal Tube
292 ETD Estimated Time of Death
293 ETOH Ethyl Alkohol
294 ETM Erosin of Teeth Medicine
295 EXO Exodonti
296 Exp Expired
297 EXT Extirpasi
F
298 F Female
299 FA Fluor Albus
300 FAM Fibroadenoma Mammae
301 FAS Fetal Alcohol Syndrome
302 FBG fasting blood glucose
303 FC Febris Convultion
304 FDC Fixed-Dose Combination
305 FFP Fresh Frozen Plasma (Jenis Darah)
306 FIO2 Fraksi oksigen yang diinspirasi
307 FL Flakon
308 FMD Foot Hand Mouth Disease
309 FOB Foot Of Bed
310 FT Fisioterapi
311 FTN Full Term Nursery
312 FTP Faillure To Progress
313 FTT Failure To Thrive (Gagal Tumbuh)
314 FU Follow Up
315 FUO Fever of Undetermined Origin
316 FV Fibrosis Vitreus
317 Fx Fracture
G
318 G Gravida
319 GA General Anesthesi
320 GALT Gut Associated Lymphoid Tissue
321 GB Gall Bladder
322 GBD Gall Bladder Disease
323 GBS Gall Bladder Series
324 GBS Gulian Bare Syndrome
325 GC Gonococcus
326 GD Gula Darah
327 GDP Gula Darah Puasa
328 GDPP Gula Darah Post Prandial
329 GDR Gross Death Rate
330 GDS Gula Darah Sewaktu
331 GE Gastro Enteritis
332 GEA Gastro Enteritis Akut
333 GERD Gastro Esophageal Reflux Disease
334 GIT Gastro Intestinal Tractus
335 GMKG Gingivitis Marginalis Kronis Generalis
6
336 GMO Gangguan Mental Organik
337 GNA Glumerulo Nefritis Acute
338 GNAPS Glomerulonefritis Acute Post Streptococcus
339 GNC Glomerulus Nephritis Chronic
340 GO Gonorhoe
341 GP Gangren Pulpa
342 GR Gangren Radix
343 GPA Gravida - Partus - Abortus
344 GSW Gun Shot Wound
345 GTT Gutata
346 GU Genito Urinary
H
347 H Hodge
348 H&N Head and Neck
349 H&P History and Physicall
350 H/L Hepar dan Lien
351 H/O History Of
352 HA Head Ache
353 HAP Hospital Acquired Pneumonia
354 HBL Hospital By Laws
355 HBV Hepatitis B Virus
356 HCCU High Care Cardiac Unit
357 HCM Hypertrophy Cardiomyopaty
358 HCV Hepatitis C Virus
359 HCM Hypertrophy Cardiomyopaty
360 HCO3 Asam Bicarbonate
361 HCT Hydrochloro Thiazide
362 HCU High Care Unit
363 HD Hemodialysis
364 HDN Haemolytic Disease of The New Born
365 HF Heart Failure
366 HH Hiatal Hernia
367 HHD Hypertensive Heart Disease
368 HI Head Injury
369 HIE Hypoxia Ischemic Encephalopaty
370 HIL Hernia Inguinalis Lateralis
371 HIV Human Immunodeficiency Virus
372 HL Hearing Loss
373 HLHS Hypoplastic Left Heart Syndome
374 HPHT Hari Pertama Haid Terakhir
375 HPL Hari Perkiraan Lahir
376 HPP Haemorhagic Post Partum
377 HNP Hernia Nucleus Pulposus
378 HOB Head Of Bed
379 HOCM Hypertrophy Obstructive Cardiomyopaty
380 HOH Hard of Hearing
381 HONK Hiperosmolar Non Ketotik
382 HPP Hemorrhagic Post Partum
383 HPV Human Papiloma Virus
384 HR Heart Rate
385 HRB Hiper Reaktive Bronchus
386 HRD Hypertension Renal Disease
387 HS Hypermetrop Simplex
388 HSP Henoch Schonlein Purpura
389 HT Hypertensi
390 HVA Homo Vanilat Acid
391 Hx History
392 HZO Herpes Zooster Ophthalmica
7
 I
393 I&O Intake and Output
394 I.M.M In Manus Media
395 IBD Inflammatory Bowel Disease
396 IBS Irritable Bowel Syndrome
397 ICCE INTRA CAPSULAR CATARACT EXTRACTION
398 ICD Implanted Cardiac Defibillator
399 ICD buku pedoman pemberian kode diagnosa
340 ICPM buku pedoman pemberian kode tindakan
341 ICU intensive care unit
342 ICW intra cellular water
343 IDU Injecting Drug User
344 IDW Interdental Wiring
345 IE Infective Endocarditis
346 IGD instalasi gawat darurat
347 IGT impaired glucose tolerance
348 IHD Ischemic Heart Disease
349 ILA Intra Lumbal Anesthesi
350 IMH Intramural Hematoma
351 IMS Infeksi Menular Seksual
352 IMW Inter Maxila Wiring
353 INF Infus
354 INJ Injeksi
355 INH Isoniazide
356 IP Infeksi Pulpa
357 IPCLN Infection Prevention and Control Link Nurse
358 IPCN Infection Prevention and Control Nurse
359 IPCO Infection Prevention and Control Officer
360 IPF Idiopatic Pulmonary Fibrosis
361 IR Infra Red
362 ISK Infeksi Saluran Kencing
363 ISPA Infeksi Saluran Pernapasan Akut
364 IVSD Interventricular Septal Defect
365 ITP Idiopathic Thrombocytopenic Purpura
366 IUD intra uterine device
367 IUFD Intra Uterin Foetal Death
368 IUGR Intra Uterine Growth Retardation
369 IUH Inersis Uteri Hipotonik
370 IV Intra Vena
371 IVB Insufficiency Vertebro Basiller
372 IVFD Intra Venouse Fluid Drip
373 IVH Intra Ventricular Haemorhagic
374 IVP intra venous pyelography
J
375 JOAG Juvenile Open Angle Glaucoma
376 JPKMM Jaminan Pelayanan Kesehatan Masyarakat Miskin
377 JUKNIS Petunjuk Teknis
K
378 K Kalium
379 KAD Ketoacidosis Diabeticum
380 KCl kalium chloride
381 KENANGA Ruang perawatan untuk kasus dalam kelas satu & tiga
382 KET Kehamilan Ektopic Terganggu
383 KGB Kelenjar Getah Bening
384 KLB Kejadian Luar Biasa
385 KLPCM ketidak lengkapan pengisian catatan medis
386 KLS kidney, liver, spleen
387 KOP Kartu Obat Pasien
8
388 KP Koch Pulmonum
389 KPD Ketuban Pecah Dini
390 KSI Katarak Senillis Immature
391 KSM Kelompok Staf Medis
392 KSM Katarak Senilis Mature
393 KU Keadaan Umum
394 KUB kidney, ureter, bladder
395 KVO keep vein open
L
396 LI Leopold 1
397 L II Leopold 2
398 L III Leopold 3
399 L IV Leopold 4
400 LA Myxoma Left Atrial Myxoma
401 Lab Laboratorium
402 LAD Left Axis Defiation
403 LAFB Left Atrial Fasicular Blok
404 LBBB Left Bundle Branch Blok
405 LBP Low Back Pain
406 LBW Low Birth Weight
407 LCSW Licensed Clinical Social Worker
408 LD Lingkar Dada
409 LED Lupus Eritematosis Diskoid
410 LES lower esophageal spinchter
411 LFT liver function tests
412 LGA Large for Gestational Age
413 LILA Lingkar Lengan Atas
414 LK Lingkar Kepala
415 LLQ Lower Left Quadrant
416 LMP Last Menstrual Period
417 LOC laxative of choice (unacceptable abbreviation)
418 LOKET tempat pendaftaran pasien
419 LOS Long Of Stay
420 LOT Lotion
421 LP Lumbal Punksi
422 LP Lingkar Perut
423 LPFB Left Posterior Fasicular Blok
424 LPR Laringopharingitis
425 LRQ Low Right Quadrant
426 LS Korset Lumbo Sacral Korset
427 LTC Long Term Care
428 LUQ Left Upper Quadrant
429 LVH Left Ventricular Hypertrophy
M
430 M Male
431 M&M Morbidity & Mortality
432 M. Leprae Mycobacterium Leprae
433 M. TB Mycobacterium Tuberculosis
434 MAOI Mono Amine Oxidase Inhibitor
435 MAS Meconium Aspirasi Syndrome
436 MAT Multifocal Atrial Tachycardia
437 MCTD Mixed Connective Tissue Disease
438 MDD Major Depressive Disorder
439 MDR Multi Drugs Resistence
440 MDS Myelodysplastic Syndrome
441 Mec Meconium
442 Medsurg medical surgery
443 mEq milliequivalents
9
444 mEq/L milliequivalents per liter
445 met(s) metastasis
446 MG Myastenia Gravis
447 MH Morbus Hansen
448 MHL Mix Hearng Loss
449 MI Myocardial Infarction
450 MICU medical intensive care unit
451 mM millimole
452 mmHg millimeters of Hg (mercury)
453 MO mineral moil
454 MOM milk of magnesia
455 Mono monocyte
456 Mosm milliosmol
457 MOW Metode Operasi Wanita
458 MR Mitral Regurgitasion
459 MRI magnetic resonance imaging
460 MRSA methicillin resistant staphilococcusaureus
461 Ms multiple sclerosis
462 MS mitral stenosis
463 MSCT Multiple Slice Compute Tomography
464 MSW master of social work
465 MT medical technologist
466 MTCT Mother To Child Transmission
467 MVA Motor Vehicle Accident
468 MVP Mitral Valve Prolaps
469 MVR Mitral Valve Replacement
470 MVr Mitral Valve repair
N
471 N&V nausea and vomitting
472 N/A not available
473 NAD NO ACUTE DISTRESS
474 NAS NO ADDED SALT
475 NCCP Non Cardiac Chest Pain
476 NDR net deaths rate
477 NEC Necrotizing Entero Colitis
478 NET Neurolisis Epidermal Toxic
479 NGT Nasogastric Tube
480 NGU Non-Gonococcal Uretritis
481 NH Neonatal Hiperbilirubinemia
482 NH(P) nursing home (placement)
483 NHL Non Hodgkin Lymphoma
484 NHML Non Hodgkin Malignant Lymphoma
485 NICU Neonatal Intensive Care Unit
486 NKA No Known Allergies
487 Nn Nona
488 NOS not otherwise specified
489 NPDR Non Proliferative Diabetic Retinopathy
490 NPH Normo Pressure Hydrosefalus
491 NPO nile per os (nothing by mouth)
492 NpOp nasopharing oropharing
493 Ns nurse
494 NS Nephrotic Syndrome
495 NSAID non steroid anti-inflammatory drug
496 NSTEMI Non ST elevasi myocard infarct
497 NTG Normo Tension Glaukoma
498 NVD nausea, vomiting, diarrhea
499 NVR Normo Venticular Response
500 Ny Nyonya
10
501 NYHA Fc I-IV New York Heart Association Function Class I-IV
O
502 O2 Oxygen
503 O2 Sat Oxygen Saturation
504 OA Osteo Artritis
505 OAT Obat Anti Tuberkulosa
506 OB Obstetrics
507 OBS Organic Brain Syndrome
508 OC Oral Contraceptive
509 OD Occuli Dextra
510 ODHA Orang Dengan HIV / AIDS
511 ODNL Obstruksi Ductus Naso Lakrimal
512 ODS Oculi Dextra Sinistra
513 OE Otitis Externa
514 OF Observasi Febris
515 OGT Orogastric Tube
516 OH Oral Higiene
517 OHO Obat Hipoglikemik Oral
518 Oint Ointment
519 OK Operation Khamber
520 OMA Otitis Media Acuta
521 OMC Otitis Media Chronic
522 OMI Old Myocard Infarct
523 OMP Otitis Media Perforata
524 OMSK Otitis Media Supuratif Kronik
525 OOB Out of bed
526 OPA Oro Pharingeal Airway
527 OR Operating room
528 OREF Open Reduksi External Fixtion
529 ORIF Open Reduction Interternal Fixation
530 Ortho Ortopedi
531 OS Occuli Sinistra
532 OSAS Obstructive Sleep Apnoea Syndrome
533 OSNA Obstruksi Saluran Nafas Atas
534 OT Occupational Therapy
535 OTC Over the counter
P
536 P Para
537 P&A Percussion and auscultation
538 PA Patologi Anatomi
539 PACG Primary Angle Closure Glaucoma
540 PACU Post Anaesthesia Care Unit
541 PACS Picture Archiving and Communication System
542 PAD Peripheral Artery Disease
543 PAP Pintu Atas Panggul
544 PAT/SUT Paraxional Atrial Trachycardi
545 Path Pathology
546 PAU Penetrating Atherosclerotic Aortic
547 PB Panjang Badan
548 Pb Plumbum
549 PC Post Coenam
550 PC IOL Posterior Chamber Intra Ocular Lens
551 PCA Patient Controlled Analgesia
552 PCH Pernafasan Cuping Hidung
553 PCI Percutaneous Coronary Intervension
554 PCM Protein Calori Malnutrition
555 PCO Posterior Capsule Opacity
556 PCOD Polycystic ovarian disease
11
557 PCR Polimerase Chain Reaction
558 PD Physical Diagnostic
559 PDA Patent ductus arteriousus
560 PDR Proliferative Diabetic Retinopathy
561 PE Pulmonary Emboly
562 PEB Pre Eklampsi Berat
563 PER Pre Eklampsi Ringan
564 PEEP Positive end expiratory pressure
565 PERRLA Pupils equal, roun, reactive to light and accommodation
566 PFT Pulmonary function test
567 PH Pulmonary Hypertension
568 PHN Post Herpetic Neuralgia
569 PICC Peripherally inserted central catheter
570 PICU Pediatric intensive care unit
571 PID Pelvic inflammatory disease
572 PIP Positive inspiratory pressure
573 Pit. Alba Pitriosis Alba
574 PJB Penyakit Jantung Bawaan
575 PKBRS Pelayanan keluarga berencana rumah sakit
576 PKU Phenylketonuria
577 PLC Pityriosis Lichenoides Chronica
578 PLEVA Pityriosis Lichenoides et. Vurioliformis
579 PMH Past medical history
580 PMS Penyakit Menular Seksual
581 PMTCT Prevention of Mother To Child Transmission
582 PN Parenteral nutrition
583 PNA Pyelonephritis Acute
584 PNC Peri Natal Care
585 PO Per Oral
586 PO; Phone Order
587 POAG Primary Open Angle Glaucoma
588 POC Perioral Cyanosis
589 POD# Postoperative day#
590 PONEK Pelayanan Obstetri Neonatal Emergenci Komprehensif
591 POST OP Post Opperative
592 PP Post Partum
593 PPBS Postprandial blood suger
594 PPCM Peripartum Cardiomyopathy
595 PPM Permanent Pace Maker
596 PPOK Penyakit Paru Obstruktif Kronis
597 PPP Perdarahan Post Partum
598 PPT Placenta Previa Totalis
599 PPV Pengeluaran Per Vagina
600 PR Per Rectum
601 PR Pulmonic Regurgitasion
602 Preop Preoperative
603 PRN Pro re nata (as necessary)
604 PROG Prognosis
605 PS Pulmonic Stenosis
606 PSA Prostate Specific Antigen
607 PT Physical Therapy
608 PTA Prior to admission/arrival
609 PTI Preterm Infant
610 PUD Peptic Ulcer Disease
611 PUD Perdarahan Uterus Disfungsional
612 PULM Pulmonary
613 pulpak Pulang paksa
614 PULV Pulvus
12
615 PV Pytiriasis Versicolor
616 PVC Premature Ventricular Contraction
617 PVD Posterior Vitreus Detachment
618 PVR Proliperatif Vitreo Retinophati
Q
619 Q Every
620 QD;qd Every day (Unacceptable abbreviation)
621 QH;qh Every hour
622 QOD;qod Every other day (unacceptable abbrevitation)
R
623 R Respiration
624 R Right
625 R/ Resep
626 RA Rheumatoid Arthritis
627 RA (An) Regional Anestesi
628 RAD Right Axis Defiation
629 RAJAL rawat jalan
630 RANAP rawat inap
631 RAO Right Anterior Oblique
632 RBBB Right Bundle Branch Blok
633 RC Reflex Cahaya
634 RD Retinal Detachmen
635 RDS Respiratory Distress Syndrome
636 RESUME Ringkasan masuk keluar catatan pasien
Memisahkan berkas yang penting dari semua berkas rekam
637 RETENSI medis
638 RG Rendah Garam
639 Rh Rhesus factor (will be + or)
640 RHC Right Heart Cathetherization
641 RHD Rheumatic Heart Disease
642 RHF Right Heart Failure
643 RIA radiommunoassay
644 RL ringer lactate
645 RLE right lower extremity
646 RLL right lower lobe
647 RLQ right lower quadrant
648 RM Retardasi Mental
649 RM Rekam Medis
650 RN registered nurse
651 ROM Range Of Motion
652 ROP Retinopathy Of Prematurity
653 ROS review of symptoms
654 RQ respiratory quotien
655 RR Recovery Room
656 RR Respiratory Rate
657 RRR Regular Rate and Rhytm
658 RT Radiation therapy
659 RUE right upper extremity
660 RUQ right upper quadrant
661 RVH Right Ventricular Hypertrophy
662 RVHD Right Ventricular Heart Disease
663 RVR Rapid Ventricular Respone
S
664 S Suhu
665 S Sferis (mata)
666 S&S, S/S signs and symptoms
667 S. Scabiei Sarcoptei Scabiei
668 S/I Sclera Ikterik

13
669 S/O sign et out
670 S/P;s/p status post
671 SA blok 1-3 Siniatrial Blok 1-3
672 SAB Subarachnoid Bleeding
673 SABE Subacute Bacterial Endocarditis
SADT Sediaan Apus Darah Tepi
674 SAH Subabarachniod Hemorrhage
675 SAP Stable Angina Pectoris
676 SB small bowel; short bowel
677 SB Sinus Bradicardya
678 SBE shortness of breath on exertion
679 SBO Small Bowel Obstruction
680 SBP Spontan Bacterial Peritonitis
681 SC Sectio Caesaria
682 SCC Squamous Cell Carcinoma
683 SCTP Seksio Cesarea Transperitonealis Profunda
684 SCN special care nursery
685 SDH Subdural Hematome
686 SEP Surat Elegabilitas Peserta
687 SGA Small for Gestational Age
688 SGOT Serum Glutamic Oxaloacetic Transaminase
689 SGPT Serum Glutamic Pyruvate Transaminase
690 SH Sirosis hati
691 SIADH Syndrome of Inappropriate Antidiuretic Hormone
692 SICE Small Incision Cataract Extraction
693 SIDS Sudden Infan Death Syndrome
694 SIRS Sistem Informasi Rumah Sakit
695 SJS Steven Johnson Syndrome
696 SL Scalp Lotion
697 SLE Systemic Lupus Erythermatosus
698 SN Syndroma Nephrotis
699 SNF Skilled Nursing Facility
700 SNHL Sensori Neural Hearing Loss
701 SO Significant other
702 SOAP Subjective, objective, assessment, plan
703 SOB Shortness of breath
704 SOL Space Occupaying Lession
705 SOPT Sindrom Obstruksi pasca TB
706 SPO Standar Prosedur Operasional
707 SPO2 Saturasi Oksigen
708 SR Sinus Rhythm
709 SS Systemic Sclerosis
710 SSP Sususnan Saraf Pusat
711 SST Susunan Saraf Tepi
712 SSS Sick Sinus Syndrome
713 SSSS Staphylococcal Scalded Skin Syndrome
714 ST Speech Terapi
715 Stat Statim (immediately)
716 STD Sexually Transmitted Disease
717 STEMI ST Elevasi Myocard Infarct
718 STGO Suspect Tumor Ganas Ovarium
719 STI Sexually Transmitted Infection
720 Strep Streptococcus
721 STT Soft Tissue Tumor
722 Subq Subcutaneous
723 SUC Signa Usum Cognitus
724 SUE Signa Usum Externum
725 Supp Suppository
14
726 Susp. Suspek
727 Susp Suspension
728 SVES Supraventriculer Extrasystole
729 SVR Slow Ventricular Response
730 SVT Supra Ventricular Tachycardia
731 SWD Short Wave Diathermy
732 SYR Sirup
T
733 T Tensi/tekanan darah
734 T&C Type and crossmatch
735 T. Tinea
736 T.A.K Tidak Ada Kelainan
737 Tab Tablet
738 TAC Temporal artery catheter
739 Tachy Tachycardia
740 TAH Total Abdominal Hysterectomy
741 TAVB Total Atrio Ventricular Block
742 TB Tuberculosis
743 TB Tinggi badan
744 TBLC term birth, living child
745 TBSA total burn surface area
746 TBW total body water
747 TD Tekanan Darah
748 TE Tonsilektomi
749 Telp Telepon
750 TEN Toxic Epidermal Necrolisis
751 TF Tube feeding
752 TFA Tonsilofaringitis acute
753 TFU Tinggi Fundus Uteri
754 TMJ Temporo Mandibular Joint
755 TG Trigliserida
756 TGL Tanggal
757 TGN Trigeminal Neuralgia
758 Th Tahun
759 Th/ Terapi
760 THD Thyroid heart disease
761 THR Total hip replacement
762 TI Term Infant
763 TIA Transient Ischemic Attack
764 Tid Three time a day
765 TIK Tekanan Intra Kranial
766 Ting Tingtura
767 TIO Tekanan Intra Okuler
768 TJL Tumor jaringan lunak
769 TKTP Tinggi Kalori Tinggi Protein
770 TL Traksi Lumbal
771 TM Tumor Mammae
772 TMJ Temporo Mandibular Joint
773 TN Tuan
774 TO Telephone order
775 TOF Tetralogy of Fallot
776 TOI Turn over interval
777 Tol Tolerate, tolerated, tolerance
778 Top Topically
779 Tpm Tetes Per Menit
780 TPM Transient Pace Maker
781 TPN Total parenteral nutrition
782 TR Tricuspid Regurgitasion
15
783 TS Tricuspid Stenosis
784 TT Tetanus Toxoid
785 TTH Tension Type Headache
786 TTIK Tekanan Tinggi Intra Kranial
787 TTN Transitory Tachipnoe of Newborn
788 tts tetes
789 TTV Tanda Tanda Vital
790 TURP Transurethral Resection of Prostate
791 TV Tinea Versicolor
792 TVP Trans Vesica Prostatectomy
793 TVr Tricuspid Valve repair
794 TWE Tap water Enema
795 Tx Treatment
U
796 U.u unit(unacceptable abbreviation)
798 UAC Umbilical Artery Catheter
799 UAO Upper airway obstruction
800 UAP Unstable Angina Pectoris
801 UE Usus Externa
802 UGA Uretritis Gonorrhea Acute
803 UOP Urinary out put
804 Up ad lib up (out of bed) as desired (adlibitum)
805 UR Utilization review
806 Urol Urology; urologist
807 URTI Upper respiratory tractus infection
808 USG Ultra sono graphy
809 USP United States pharmacopeia
810 UTI Urinary tract infection
V
811 V Ventricular
812 VAP Ventilator Associated Pneumonia
813 VCT Voluntary Counseling and Testing
814 VD Vessel Disease
815 Vent Ventilator
816 VE Vaccum Extraction
817 VES Ventricle Extra Systole
818 VF Ventricular Fibrillation
819 VH Vaginal Hysterectomy
820 VH Vitreus Haemorhage
821 VHD Valvular Heart Disease
822 VL Vulnus Laceratum
823 VKC Vernal Kerato Conjunctivitis
824 VLBW Very low birth weight
825 VO Verbal order
826 VO2 Oxygen consumption
827 VOD Visus Oculi Dexta
828 VOS Visus Oculi Sinistra
829 Vol Volume
830 VP Venous Pressure
831 VRSA Vancomycin resistant staph aureus
832 VS Vital Signs
833 VSD Ventricular Septal Defect
834 VT Ventricular Tachycardia
835 VTP Ventilasi Tekanan Positif
836 VU Visica Urinaria
W
837 W/ With
838 w/d well developed
16
 840 W/U;w/u workup
841 WB weight bearing
842 WBN well baby nursery
843 WC; w/c wheelchair
844 WD Well developed
845 WF;wf White female
846 WFL within functional limits
847 WN;w/m White male
848 WN;w/n well nourished
849 WNL within normal limits
850 Wo/ Without
851 WPW Wolff-Parkinson-White
852 WSD Water Sealed Drainage
853 Wt weight
X
854 X time
855 Xmatch cross match
Y
856 YO;y/o year(s) old
857 YTD year to date
Z
858 Zalf Salep
859 ZD Zink Deficiency
860 ZIFT Zygote Intra Fallopian Transfer

RUANG PERAWATAN

ANGGREK ruang perawatan untuk kasus bedah

ASTER A & B ruang perawatan vip
ANYELIR ruang perawatan stroke center dan HCU
CEMPAKA ruang perawatan untuk kasus dalam perempuan kelas tiga
DAHLIA ruang perawatan untuk kasus kebidanan
JASMIN ruamg perawatan bedah khusus dan dalam kelas 3
KENANGA ruang perawatan kasus dalam kelas satu dan dua
MELATI ruang perawatan bayi baru lahir
SAKURA ruang perawatan kasus dalam laki dan perempuan kelas 3
TANJUNG ruang perawatan khusus ANAK-ANAK
TULIP ruang perawatan kelas 1 , kecuali bedah umum dan orthopedi
WIJAYA KUSUMAH ruang perawatan dalam kelas 3 isolasi TB

Symbols

↓ decrease x letak operasi

↑ increase infus cairan

♀ famale infus darah (transfusi)

♂ male area tubuh

- tidak menemukan pemeriksaan # fraktur

yang signifikan
-/- tidak menemukan pemeriksaan +/+ menemukan pemeriksan
yang signifikan pada dua bagian yang signifikan pada dua
bagian
+ menemukan pemeriksaan yang Ø pembukaan portio
signifikan
± kurang lebih

17
18