DAFTAR ISI

SURAT KEPUTUSAN DIREKTUR

KATA PENGANTAR .......................................................................................... i
DAFTAR ISI ........................................................................................................ ii
BAB I : PENDAHULUAN
1.1 Latar Belakang ............................................................................... 1
1.2 Tujuan Pedoman ............................................................................ 1
1.3 Ruang Lingkup Pelayanan ............................................................. 1
1.4 Batasan Operasional ....................................................................... 2
1.5 Landasan Hukum ........................................................................... 4
BAB II : STANDAR KETENAGAAN
2.1 Kualifikasi Sumber Daya Manusia ................................................. 5
2.2 Distribusi Ketenagaan .................................................................... 6
2.3 Pengaturan Jaga ............................................................................. 10
BAB III : STANDAR FASILITAS
3.1 Denah Ruangan Unit Rekam Medis ............................................... 11
3.2 Standar Fasilitas ............................................................................ 12
BAB VI : TATALAKSANA PELAYANAN
4.1 Sitem Rekam Medis ....................................................................... 13
4.2 Tata Cara Penerimaan Pasien ......................................................... 14
4.3 Perekaman Kegiatan Pelayanan Rekam Medis ............................... 15
4.4 Daftar Simbol dan Daftar Singkatan ............................................... 21
4.5 Proses Pengolahan Berkas Rekam Medis........................................ 27
4.6 Korespondensi Rekam Medis ......................................................... 30
4.7 Sistem Kearsipan Rekam Medis ..................................................... 32
4.8 Pertanggungjawaban Terhadap Berkas Rekam Medis ..................... 34
4.9 Kepemilikan dan Kerahasiaan Rekam Medis .................................. 35
4.10 Persetujuan/ Penolakan Tindakan (Informed Consent) .................. 37
4.11 Pemberian Informasi Kepada Orang/Badan Yang Berwenang ...... 37
4.12 Berkas Rekam Medis di Pengadilan.............................................. 39
4.13 Sarana Penunjang Pelayanan di Unit Rekam Medis ...................... 39
BAB V : LOGISTIK
5.1 Logistik Berkas Rekam Medis ........................................................ 41
BAB VI : KESELAMATAN PASIEN
6.1 Pengertian ..................................................................................... 43
6.2 Tujuan ........................................................................................... 43
6.3 Indikator ........................................................................................ 43
6.4 Standar Keselamatan Pasien ........................................................... 43
6.5 Macam-Macam Kejadian tidak Diharapkan.................................... 44

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 6.6 Tata Laksana .................................................................................. 45
BAB VII : KESELAMATAN KERJA
7.1 Keselamatan Kerja di Unit Rekam Medis ....................................... 46
BAB VIII : PENGENDALIAN MUTU
8.1 Menjaga Standar Mutu ................................................................... 47
8.2 Indikator Mutu Di Unit Rekam Medis ............................................ 47
BAB IX : PENUTUP ........................................................................................ 50
DAFTAR PUSTAKA

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