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  • Isi Rekam Medis Puskesmas Yang Lengkap

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SURAT KUASA PEMAPARAN ISI REKAM MEDIK POWER OF ATTORNEY FOR MEDICAL RECORDS Yang bertandatangan di bawah ini / The undersigned : Nama Lengkap / Full Name : Jenis kelamin / Sex : Lakilaki / Male Perempuan.

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Nomor rekam medis diberikan oleh petugas pendaftaran pasien rawat jalan dengan menggunakan sistem manual yaitu menggunakan buku sehingga setiap pemberian nomor pasien baru dicatat di dalam buku register. Sistem penomoran rekam medis di Puskesmas Guntung Payung terdiri dari 8 angka nomor rekam medis.

Selain cerminan praktik kedokteran yang baik, rekam medis juga merupakan bukti ketepatan perawatan terhadap pasien. Berikut rekam kesehatan medis yang baik: Akurat menggambarkan proses dengan hasil akhir yang terukur secara tepat. Analisis hasil ukuran yang lengkap, mencakup seluruh kekhususan pasien.

Adapun pada dokumen rekam medis untuk pasien rawat inap, sekurang-kurangnya berisi: identitas pasien. tanggal dan waktu. hasil anamnesis berupa keluhan dan riwayat penyakit. hasil pemeriksaan fisis dan penunjang medik. diagnosis. rencana penatalaksanaan. pengobatan atau tindakan. persetujuan tindakan bila diperlukan.

Setiap pelayanan yang diberikan puskesmas kepada pasien diperlukan sebuah berkas rekam medis. Rekam medis adalah berkas yang berisikan catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain yang telah diberikan kepada pasien (Permenkes RI No. 269, 2008).

Kompetensi yang Harus Dimiliki Perekam Medis dan Informasi Kesehatan Profesionalisme yang Luhur, Etika dan Legal. ... Mawas Diri dan Pengembangan Diri. ... Komunikasi Efektif. ... Manajemen Data dan Informasi Kesehatan. ... Keterampilan Klasifikasi Klinis, Kodifikasi Penyakit dan Masalah Kesehatan Lainnya, serta Prosedur Klinis.

Isi Rekam Medis Identitas pasien. Tanggal dan waktu tindakan. Hasil anamnesis, setidaknya tentang keluhan dan riwayat penyakit. Hasil pemeriksaan fisik dan penunjang medis. Diagnosis. Rencana penatalaksanaan. Pengobatan yang diberikan kepada pasien. Informasi pendukung lainnya.

Data rekam medis merupakan data dokumen yang berisi riwayat penyakit yang diderita pasien. Data tersebut digunakan sebagai isi rekam yang akan dipakai untuk pengobatan dan pemeliharaan kesehatan pasien. Selain itu, rekam medis berfungsi juga untuk bukti penegakan hukum dan disiplin kedokteran serta penegakan etika ...

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232