DAFTAR ISI

Kata Pengantar ………………………………………………………………………. i

Daftar Isi ………………………………………………………………………. ii
Daftar Tabel / Denah / Alur ............................................................................................. iii
SK.Direktrur RS Mitra Medika ......................................................................................... iv
BAB I PENDAHULUAN ……………………………………….... 1
A. Latar Belakang .................................................................................... 1
B. Tujuan Pedoman ................................................................................ 2
C. Ruang Lingkup Pelayanan ................................................................. 2
D. Batasan Operasional ........................................................................... 3
E. Landasan Hukum ............................................................................... 3
BAB II PENGERTIAN DAN KEGUNAAN REKAM MEDIS …………... 4
A. Falsafah Rekam Medis ...................................................................... 4
B. Pengertian Rekam Medis ................................................................... 4
C. Tujuan Rekam Medis ........................................................................ 4
D. Kegunaan Rekam Medis .................................................................... 5
BAB III ASPEK HUKUM REKAM MEDIS .........................................……... 7
A. Pertanggung Jawaban Terhadap Rekam Medis ................................. 7
B. Tanggung Jawab Dokter Yang Merawat ............................................ 7
C. Tanggung Jawab Petugas Rekam Medis ............................................ 7
D. Tangung Jawab Pimpinan Rumah Sakit ............................................. 8
E. Tanggung Jawab Staff Medis ........................................................... 9
F. Pemilikan Rekam Medis ................................................................... 9
G. Kerahasiaan Rekam Medis ................................................................. 10
H. Persetujuan Tindakan Medis (Informed Consent) ............................ 10
I. Pemberian Informasi Rekam Medis ................................................... 11
J. Rekam Medis di Pengadilan ............................................................. 11
BAB IV STANDAR KETENAGAAN …………........................................... 13
A. Kualifikasi Sumber Daya Manusia ................................................... 13
B. Distribusi Ketenagaan ..................................................................... 13
C. Pengaturan Jaga ................................................................................ 13
BAB V STANDAR FASILITAS ……………………………....................... 14
A. Denah Ruang Kerja Rekam Medis .................................................... 14
B. Standar Fasilitas ................................................................................. 17

BAB VI TATA LAKSANA PELAYANAN ………………………................... 18

A. Sistem Rekam Medis ............................................................................ 18
B. Perekaman Kegiatan Pelayanan Medis ................................................. 29

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 C. Proses Pengolahan Rekam Medis.......................................................... 30
BAB VII LOGISTIK ……………………………................................................. 40
A. Penjadwalan Pelayanan Logistik ………………………................... 40
B. Prosedur Permintaan ……………………………………………........ 40
C. Prosedur Pengambilan Barang ……………………………………..... 40
BAB VIII KESELAMATAN PASIEN ……………………………...................... 41
A. Pengertian……………………............................................................. 41
B. Tujuan……………………………………………............................... 41
C. Tata Laksana Keselamatan Pasien ………………………………...... 41
BAB IX KESEHATAN DAN KESELAMATAN KERJA ………………… 44
A. Perlindungan Keselamatan Kerja Dan Kesehatan Petugas Kesehatan 45
B. Petunjuk Pencegahan Infeksi Untuk Petugas Kesehatan .................... 45
BAB X PENINGKATAN MUTU ……………………………………………... 46
A. Mutu Rumah sakit ............................................................................. 46
B. Upaya Peningkatan Mutu Rumah Sakit ........................................... 47
C. Indikator Mutu .................................................................................. 49
BAB XI PENUTUP ……………………………………………………………….. 52

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