SOP Assembling Rekam Medis Pasien
Diunggah oleh
Aldy SetyawanSOP Assembling Rekam Medis Pasien
Diunggah oleh
Aldy SetyawanASSEMBLING BERKAS REKAM
MEDIS
No. Dokumen : SOP/YK/ /IV/2022 an Kaklinik wira sakti
No. Revisi : 0/0 dokter penangguang jawab
SOP
Tanggal Terbit : 00 - 00 - 22
Halaman : 1/6
KLINIK WIRA
SAKTI dr. Nurul Hidayati
PNS III/[Link] 1989907162019032003
Assembling rekam medis merupakan proses mengumpulkan dan
mengurutkan berkas yang berisikan dokumen tentang identitas,
1. Pengertian diagnosa pengobatan, anamnesis, pemeriksaan, tindakan,
pengobatan serta pelayanan lainnya yang diberikan kepada
pasien.
Sebagai acuan penerapan langkah-langkah pengurutan
formulir rekam medis untuk mempermudah dokter dalam melihat
riwayat pengobatan pasien.
2. Tujuan
Permenkes Nomor 269/Menkes/Per/III/2008 tentang Rekam
Medis.
3. Kebijakan
4. Referensi
5. Prosedur 1. Dokumen rekam medis setelah di lakukan entri P-Care akan di
urutkan berdasarakn hari kunjungan pasien
2. Mengurutkan formulir rekam medis
a. Poli umum
ASSEMBLING BERKAS REKAM
MEDIS
No. Dokumen : SOP/YK/ /IV/2022 an Kaklinik wira sakti
No. Revisi : 0/0 dokter penangguang jawab
SOP
Tanggal Terbit : 00 - 00 - 22
Halaman : 2/6
KLINIK WIRA
SAKTI dr. Nurul Hidayati
PNS III/[Link] 1989907162019032003
I. Asessmen awal poli umum
II. Pemeriksan penunjang ( Lab, SKDP, Resume
Medis, persetujuan rujukan dan pemeriksaat
lainnya) di urutkan sesuai tanggal kunjunagn
pasien
III. Catatatn perkembangan pasien terintergritas
rawat jalan
b. Poli gigi
I. Asessmen awal poli Gigi
II. Pemeriksan penunjang ( Lab, SKDP, Resume
Medis, persetujuan rujukan dan pemeriksaat
lainnya) di urutkan sesuai tanggal kunjunagn
pasien
III. Catatatn perkembangan pasien terintergritas
rawat jalan
c. Poli KIA
I. Asessmen awal poli KIA
II. Pemeriksan penunjang ( Lab, SKDP, Resume
Medis, persetujuan rujukan dan pemeriksaat
lainnya) di urutkan sesuai tanggal kunjunagn
pasien
III. Catatatn perkembangan pasien terintergritas
rawat jalan
d. Gawat darurat
I. Asessmen awal poli gawat darurat
ASSEMBLING BERKAS REKAM
MEDIS
No. Dokumen : SOP/YK/ /IV/2022 an Kaklinik wira sakti
No. Revisi : 0/0 dokter penangguang jawab
SOP
Tanggal Terbit : 00 - 00 - 22
Halaman : 3/6
KLINIK WIRA
SAKTI dr. Nurul Hidayati
PNS III/[Link] 1989907162019032003
II. Pemeriksan penunjang ( Lab, SKDP, Resume
Medis, persetujuan rujukan dan pemeriksaat
lainnya) di urutkan sesuai tanggal kunjunagn
pasien
III. Catatatn perkembangan pasien terintergritas
rawat jalan
3. Setelah form tersusun rapin dan sesuai dengan urutan maka
akan dilakukan pengkodingan diagnose penyakit
6. Bagan Alir
-
7. Hal-hal yang
perlu
diperhatikan
8. Unit terkait Unit Rekam medis Poli Umum, Unit Poli Gigi, Unit KIA
9. Dokumen -
Terkait
10. Rekaman Historis
No. Yang dirubah Isi Perubahan Tanggal mulai diberlakukan
ASSEMBLING BERKAS REKAM
MEDIS
No. Dokumen : SOP/YK/ /IV/2022 an Kaklinik wira sakti
No. Revisi : 0/0 dokter penangguang jawab
SOP
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KLINIK WIRA
SAKTI dr. Nurul Hidayati
PNS III/[Link] 1989907162019032003
Unit : ………………………………………………………………………
Nama Petugas : ………………………………………………………………………
Tanggal Pelaksanaan : ………………………………………………………………………
Tidak Dilaksanakan
No Langkah Kegiatan Dilaksanakan
1. Dokumen rekam medis setelah di
lakukan entri P-Care akan di urutkan
berdasarakn hari kunjungan pasien
2. 4. Mengurutkan formulir rekam medis
a. Poli umum
I. Asessmen awal poli umum
II. Pemeriksan penunjang
( Lab, SKDP, Resume
Medis, persetujuan rujukan
dan pemeriksaat lainnya) di
urutkan sesuai tanggal
kunjunagn pasien
III. Catatatn perkembangan
pasien terintergritas rawat
jalan
b. Poli gigi
I. Asessmen awal poli Gigi
II. Pemeriksan penunjang
( Lab, SKDP, Resume
Medis, persetujuan rujukan
dan pemeriksaat lainnya) di
urutkan sesuai tanggal
kunjunagn pasien
ASSEMBLING BERKAS REKAM
MEDIS
No. Dokumen : SOP/YK/ /IV/2022 an Kaklinik wira sakti
No. Revisi : 0/0 dokter penangguang jawab
SOP
Tanggal Terbit : 00 - 00 - 22
Halaman : 5/6
KLINIK WIRA
SAKTI dr. Nurul Hidayati
PNS III/[Link] 1989907162019032003
III. Catatatn perkembangan
pasien terintergritas rawat
jalan
c. Poli KIA
i. Asessmen awal poli KIA
ii. Pemeriksan penunjang
( Lab, SKDP, Resume
Medis, persetujuan rujukan
dan pemeriksaat lainnya) di
urutkan sesuai tanggal
kunjunagn pasien
iii. Catatatn perkembangan
pasien terintergritas rawat
jalan
d. Gawat darurat
I. Asessmen awal poli gawat
darurat
II. Pemeriksan penunjang
( Lab, SKDP, Resume
Medis, persetujuan
rujukan dan pemeriksaat
lainnya) di urutkan sesuai
tanggal kunjunagn pasien
III. Catatatn perkembangan
pasien terintergritas rawat
jalan
3. Setelah form tersusun rapin dan sesuai
dengan urutan maka akan dilakukan
pengkodingan diagnose penyakit
ASSEMBLING BERKAS REKAM
MEDIS
No. Dokumen : SOP/YK/ /IV/2022 an Kaklinik wira sakti
No. Revisi : 0/0 dokter penangguang jawab
SOP
Tanggal Terbit : 00 - 00 - 22
Halaman : 6/6
KLINIK WIRA
SAKTI dr. Nurul Hidayati
PNS III/[Link] 1989907162019032003
Compliance rate (CR) : ……………………………..%
…………………………, ………………..
Pelaksana/Auditor
……………….………………………….
NIP:
Common questions
Didukung oleh AIProper medical record assembling directly impacts patient safety and care quality by ensuring that all relevant patient information is readily accessible and accurate. This reduces the risk of medical errors, ensures continuity of care, and enhances communication among healthcare providers. Consistent documentation helps in monitoring patient outcomes and identifying trends or potential issues early, ultimately leading to better care coordination and improved patient health outcomes .
Healthcare providers might face challenges such as maintaining consistency in document organization across different clinics, ensuring accurate and timely updates to patient progress notes, managing large volumes of records efficiently, and training staff to comply with SOPs. Additionally, the need to adhere to regulations and integrate new technologies can complicate the process further. These challenges require coordinated efforts to standardize practices and ensure data integrity .
The assembling procedures facilitate the work of physicians and medical staff by providing a structured framework for organizing patient information efficiently. It allows quick access to patient histories, diagnostics, and treatment plans, thus supporting accurate and timely decision-making. The organization of documents according to visit dates also aids in tracking patient progress systematically, which is especially critical in follow-up care and multidisciplinary cases .
The SOP framework ensures compliance and accountability by providing detailed and standardized instructions for organizing, updating, and coding patient records. It includes roles and responsibilities for each step in the process, thereby promoting accountability among staff. Regular audits and historical records of changes further support adherence to guidelines and allow easy identification and rectification of any deviations, thus maintaining high standards of data integrity and regulatory compliance .
The SOP framework at Klinik Wira Sakti entails collecting and ordering medical documents based on the patient's visit dates through general, dental, maternity, and emergency clinics. It involves initial assessments, conducting additional examinations, maintaining integrated outpatient progress notes, and ensuring that documents are correctly assembled for subsequent diagnostic coding. The process is guided by specific documents with detailed steps to ensure accuracy and compliance .
The main objectives of assembling medical records are to compile and order documents containing patient identity, diagnosis, treatment history, anamnesis, examinations, procedures, and other services provided to patients. This process serves as a reference for organizing medical record forms to facilitate doctors in viewing a patient's treatment history .
The coding process is significant as it involves assigning specific codes to diagnoses, which is crucial for categorizing, retrieving, and analyzing patient information and data efficiently. This step follows the orderly assembly of medical record documents and ensures accurate diagnosis reporting, which is vital for billing, statistical analysis, and improving patient care .
The historical record of changes, or 'Rekaman Historis,' plays a role in tracking amendments made to the medical records management procedures. It provides a documented trail of what changes were implemented, their content, and when they were enacted. This is essential for maintaining transparency, auditing processes, and ensuring that all staff members are informed of the latest procedural updates which contribute to consistent and efficient record management .
Regulatory policies like Permenkes Nomor 269/Menkes/Per/III/2008 have a profound impact on medical record management by setting standards for documentation, data security, patient confidentiality, and record retention. They ensure that healthcare providers maintain proper documentation practices, which are crucial for legal compliance, quality care, and operational efficiency. Adherence to these regulations can also enhance patient trust and service delivery by ensuring accuracy and accountability in patient data handling .
In the general, dental, and maternity clinics, the initial assessments are specific to their respective specializations (e.g., general, dental, or maternity). In all clinics, supporting examinations such as lab tests, medical resumes, referral approvals, and other assessments are organized according to the patient's visit dates. Additionally, the integrated patient progress notes are kept up-to-date as part of the outpatient management system .