DAFTAR ISI

KATA PENGANTAR.......................................................................................... ii
BAB I PENDAHULUAN..................................................................................... 1
A. Pengertian Rekam Medis..................................................................... 1
B. Perkembangan Sistem Rekam Medis dan Informatika Kesehatan....... 1
C. Tujuan................................................................................................... 2
D. Falsafah dan Kegunaan Rekam Medis................................................. 3
E. Visi dan Misi Rumah Sakit St. Rafael Cancar...................................... 5
BAB II ORAGANISASI REKAM MEDIS.......................................................... 6
A. Organisasi Rekam Medis..................................................................... 6
B. Tugas Pokok dan Uraian Tugas............................................................ 7
BAB III PROSES PENYELENGGARAAN REKAM MEDIS........................... 12
A. Sistem Rekam Medis............................................................................ 12
B. Prosedur Rekam Medis........................................................................ 18
C. Proses Pengolahan Rekam Medis......................................................... 22
D. Analisa Mutu Rekam Medis................................................................. 25
E. Sistem Kearsipan Rekam Medis........................................................... 25
BAB IV AASPEK HUKUM REKAM MEDIS................................................... 28
A. Pertanggungjawaban Tgerhadap Rekam Medis................................... 28
B. Kepemilikan Rekam Medis dan Kerahasiaan Rekam Medis............... 30
C. Informed Consent................................................................................. 31
D. Pemberian Informasi Rekam Medis..................................................... 32
E. Rekam Medis Di Pengadilan................................................................ 33
F. Adopsi................................................................................................... 33
BAB V PENGEMBANGAN REKAM MEDIS................................................... 34
A. Program Orientasi................................................................................ 34
B. Program Pengembangan Staf............................................................... 35
BAB VI RINCIAN KERJA KLINIS.................................................................... 36
BAB VII PENUTUP............................................................................................. 41
LAMPIRAN