SISTEM PENGUMPULAN

DATA REKAM MEDIS

NURHAYATI
NUR ILAH
RESKY
ESTRIANA
RISKA
SISTEM PENGUMPULAN
REKAM MEDIS DI
RUMAH SAKIT
Sistem Pengumpulan data Rekam Medis di
Rumas Sakit

Rekam medis mempunyai peranan yang sangat penting untuk menunjang

tercapainya tertib administrasi dalam upaya peningkatan pelayanan kesehatan
di rumah sakit. Rekam medis berisikan catatan indikasi pasien, anamnese,
pemeriksaan, diagnosa, pengobatan, tindakan dan pelayanan yang diberikan
kepada pasien selama pasien berobat atau dirawat di rumah sakit, baik yang
terjadi dimasa lalu dan dimasa kini.
 •Aspek Hukum

ASPEK REKAM MEDIS

Aspek Administrasi 0 Aspek Hukum

02
1

Aspek 4
Kegunaan rekan medis
dapat ditinjau dari beberapa Aspek
aspek, antara lain : Keuangan
03 04 penelitian

Aspek Aspek
05 06 dokumentasi
pendidikan
Catatan asuhan pada pasien dianalisis setiap
6-12 bulan
kondisi utama pasien
jumlah pasien
menurut umur dan jenis
yang dirawat
1 4
kelamin
jumlah pasien
yang pulang serta catatan tentang
2
kekurangan obat,
jumlah pasien alat, dan petugas
5
meninggal  
3
Apabila catatan asuhan pada pasien ini dibutuhkan
untuk kepentingan administrasi lain pastikan bahwa
nama dan nomor identifikasi dapat dihubungkan dengan
catatan lainnya. Catatan tentang asuhan pada pasien ini
disimpan untuk minimal satu tahun.
 CATATAN PASIEN SELAMA DI RAWAT
tanggal masuk rumah diagnosis akhir dan
1 2
sakit intruksi selama
dirumah

Lama di rawat &

indikasi 3 4 terapi yang telah
diberikan

perjalanan mencakup terapi yang

penyakit 5 diberikan dan
6 lamanya, serta catatan
lanjutan selama kunjungan.
 1 2
Pencatatan Kegiatan Pengolahan data
(recording) pelayanan
rekam medik
dirumah sakit 
3 4
penyimpanan pengambilan/
(filling) peminjam berkas
Aturan dan prosedur umum dalam pengarsipan rekam
medik pasien di rumah sakit, antara lain: ketika berkas
dikembalikan, sebelum disimpan harus diperiksa dan
diurutkan dahulu untuk memudahkan penyimpanan
kembali. Penyimpanan hanya dilakukan oleh petugas
penyimpanan berkas. Berkas dengan folder yang sobek
harus segera diperbaiki dan lembaran yang lepas harus
segera disatukan dengan file induk.
SISTEM PENGUMPULAN
REKAM MEDIS DI
PUSKESMAS
 Puskesmas merupakan organisasi kesehatan
fungsional yang merupakan pusat
pengembangan kesehatan masyarakat yang
juga membina peran serta masyarakat dan
memberikan pelayanan secara menyeluruh
dan terpadu kepada masyarakat di wilayah
kerjanya dalam bentuk kegiatan pokok
Puskesmas dibagi menjadi dua, yaitu :
a.Pelayanan rawat jalan Rawat Jalan merupakan salah satu
unit kerja di Puskesmas yang melayani pasien yang berobat
jalan dan tidak lebih dari 24 jam pelayanan, termasuk seluruh
prosedur diagnostik dan terapeutik. Kartu rawat jalan adalah
formulir rekam medis yang digunakan untuk mencatat
perjalanan penyakit pasien pada saat menjalani pelayanan
rawat jalan di pelayanan kesehatan. Isi pokok formulir ini
adalah identitas pasien ,tanggal berobat,ringkasan perjalanan
penyakit,tindakan dan tanda tangan dokter yang menangani
Pelayanan.
b. Pelayanan rawat inap Berdasarkan Depkes
RI 2009, Puskesmas rawat inap adalah
Puskesmas yang diberi tambahan ruangan
dan fasilitas untuk menolong pasien gawat
darurat, baik berupa tindakan operatif 6
terbatas maupun asuhan keperawatan
sementara dengan kapasitas kurang lebih 10
tempat tidur
Pelayanan Rekam Medis di Puskesmas
Rekam medis di Puskesmas merupakan salah
satu sumber data penting yang nantinya akan
diolah menjadi informasi.

Jenis-jenis kartu atau status rekam medis yang

ada di puskesmas sangat bervariasi
sasarannya,sebagai contoh
1.Family Folder
2.Kartu Tanda Pengenal
3.Kartu Penderita dan indeks Penderita Kusta
4.Kartu Penderita dan indeks penderita TB
5.Kartu Rawat Jalan
6.Kartu Rawat Inap
7.Kartu Ibu
8.Kartu Anak
8.KMS Balita,Anak Sekolah,Ibu Hamil,dan Lansia
9.Kartu Rumah (Sanitasi)
 Vintage torn paper aesthetic agency

79% 99% 88%

Neptune Mercury Jupiter

It’s the farthest planet Mercury is the closest Jupiter is the biggest
from the Sun planet to the Sun planet of them all
 1 2
Pencatatan Kegiatan Pengolahan data
(recording) pelayanan
rekam medik
dirumah sakit 
3 4
penyimpanan pengambilan/
(filling) peminjam berkas
 1 2
Pencatatan Kegiatan Pengolahan data
(recording) pelayanan
rekam medik
dirumah sakit 
3 4
penyimpanan pengambilan/
(filling) peminjam berkas
Vintage torn paper aesthetic agency
Social network
Despite being red, Mars is a cold place

Networking
Venus is the second planet from the Sun

Website
Saturn is a gas giant and has several rings

Email marketing
Earth is the third planet from the Sun
Vintage torn paper aesthetic agency
Social network
Despite being red, Mars is a cold place

Networking
Venus is the second planet from the Sun

Website
Saturn is a gas giant and has several rings

Email marketing
Earth is the third planet from the Sun
 Vintage torn paper aesthetic agency

Copy Photography
Venus is the second planet Mercury is the closest
What do we offer? from the Sun planet to the Sun

Saturn is a gas giant and has several

rings. It's composed mostly of
Design Programming
hydrogen and helium. It was named
Jupiter is the biggest planet Mars is actually a very
after the Roman god of wealth and
of them all cold place
agriculture
 Vintage torn paper aesthetic agency
1999 2010 2015 2020

Mars Venus Saturn Jupiter

Despite being Venus is the Saturn was Jupiter is the

red, Mars is a second planet named after a biggest planet
cold place from the Sun Roman god of them all
 Vintage torn paper aesthetic agency
Helena James Sean Smith James Patterson
You can replace the image on You can replace the image on You can replace the image on
the screen with your own the screen with your own the screen with your own

Meet the team

 Vintage torn paper aesthetic agency

Name Gender
Anne Williams Female

Age Category
25-35 Mars is very cold

Audience Social network

Venus is very hot Mercury is small
Our client’s
profile
 Vintage torn paper aesthetic agency

Susan James, 35 John Travis, 54 Erica James, 28

“Despite being red, Mars is “Mercury is the closest planet “Venus has a beautiful name
actually a cold place. It's full to the Sun and the smallest in and is the second planet from
of iron oxide dust” the Solar System” the Sun”
 Vintage torn paper aesthetic agency
Case studies

Opportunity Proffer Implantation

Mercury is the closest Despite being red, Mars is Venus has a beautiful name
planet to the Sun and the actually a very cold place. and is the second planet
smallest one in the entire This planet is full of iron from the Sun. It’s terribly
Solar System oxide dust hot
 Vintage torn paper aesthetic agency

Our awards 2015 2018 2021

Award Venus Saturn Jupiter

Venus is the second Saturn was named Jupiter is the biggest

Location planet from the Sun after a Roman god planet of them all
 Vintage torn paper aesthetic agency
Our growth

50% 25% 12% 25%

Venus Mars Mercury Saturn

Venus has a Mars is full of Mercury is the Saturn is the
beautiful name iron oxide dust smallest planet ringed planet
 Vintage torn paper aesthetic agency

Our plans
Basic Pro Premium

Mercury Venus Saturn

Mercury is the closest planet Venus is the second planet It’s composed of hydrogen and
to the Sun from the Sun helium
 Vintage torn paper aesthetic agency
Jan Feb March April May
Phase 1
January 1st - March 31th

Task 1
January 1st - February 22th

Task 2
February 23th - March 31th

Phase 2
April 1st - May 27th
Vintage torn paper aesthetic agency
Checklist project Done To do
Saturn is the second-largest planet in the Solar System x
Neptune is the fourth-largest planet in the Solar System x
Despite being red, Mars is actually a cold place x
Venus has a beautiful name, but also high temperatures x
Jupiter is the biggest planet in the Solar System x
 Vintage torn paper aesthetic agency
Neptune
Neptune is the farthest
planet from the Sun

Venus Jupiter
It’s the second planet Review of Jupiter is the biggest
from the Sun planet of them all
past events

Saturn
It’s composed of
hydrogen and helium
 Vintage torn paper aesthetic agency

7579% 2099% 5088% 30

% % % %
Neptune Mercury Jupiter Saturn
Neptune is very far Mercury is the closest Jupiter is the biggest Saturn is a gas giant
away from Earth planet to the Sun planet of them all and has several rings

Some porcentages
 Vintage torn paper aesthetic agency

Marketing team profile

Job position Clients Hits accumulated

Marketing Works with premium 500k accumulated

manager customers impressions

Jupiter is the biggest Saturn is a gas giant and Venus is the second
Sara James planet of them all has several rings planet from the Sun
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