
What Definition of Medical Record?
According PERMENKES No: 269/MENKES/PER/III/2008 is medical record is a file that contains records and documents such as patient identification, examination, treatment given, as well as measures and other services that have been given to the patient. Note the writings made by the doctor or dentist about the actions done to patients in order palayanan health.
Medical Records in the form of a manual that is comprehensive and clearly written and in electronic form as required.
Medical records consist of data records of patients who performed in the ministry of health. The notes are very important for services to patients due to incomplete data can provide better information in deciding treatment, handling, medical and other actions. Physician or dentist is required to make medical records according to the rules and regulations.
What's in the Medical Record?
According PERMENKES No: 269/MENKES/PER/III/2008 data that must be included in the distinguished Medical Record for patients examined in outpatient and inpatient and emergency department. Each well in outpatient services, hospitalization and emergency room can make a medical record with the following data:
1. Outpatient
Outpatient data is entered in the medical records of at least include:
a. Patient identity
b. Date and time.
c. Anamnesis (at least complaint, history of illness).
d. Results of physical examination and medical support.
e. Diagnosis
f. Management plan
g. Treatment and / or action
h. Another service that has been given to the patient.
i. For the case of teeth and equipped with clinics and odontogram
j. Approval of action when necessary.
2. Hospitalized Patients
Patient data is entered in the medical records of at least include:
a. Patient identity
b. Date and time.
c. Anamnesis (at least complaint, history of disease.
d. Physical examination results and medical support.
e. Diagnosis
f. Management plan
g. Treatment and / or action
h. Approval of action when necessary
i. Note obsservasi clinical and treatment outcomes
j. Summary of home (discharge summary)
k. Name and signature doctor, dentist or certain health personnel who provide services ksehatan.
l. Other services provided by certain health personnel.
m. For the case of dental clinics and is equipped with odontogram
3. Emergency Room
Patient data that must be included in the medical records of at least include:
a. Patient identity
b. Condition when the patient arrived at the health-care facilities
c. Introduction to patient identity
d. Date and time.
e. Results Anamnesis (at least complaint, history of disease.
f. Physical examination results and medical support.
g. Diagnosis
h. Treatment and / or action
i. Summary of the patient's condition before leaving the emergency services and follow-up plan.
j. Name and signature doctor, dentist or certain health personnel who provide health services.
k. Means of transportation used for patients who will be transferred to other health care facilities and
l. Other services provided by certain health personnel.
Sample Patient Identification Data, among others:
- Name:
- Sex:
- Place Date of Birth:
- Age:
- Address:
- Work:
- Education:
- Blood Group:
- Marital status:
- Name of parents:
- Working Parents:
- Name of husband / wife:
Medical record data above can be added and completed according to existing needs in the health.
Organization is a collection of several people who have the same goal. Some individuals have different functions in accordance with its role. Unit medical record is an organization consisting of several units of staff and chief of medical records. The general aim of this distribution are based organizations providing health information up to date on health-care facilities.
The role of an office or attached to a task. Medical Perakam in health care facilities have two roles is the role as manager and as a staff role. Role as a manager means that the recorder must be able to perform the function of medical-managerial fungai to develop a unit medical record. Managerial functions include planning, organizing, directing, and supervision. For example, management tasks in the unit medical record that is human resource management, management of equipment and facilities include an ergonomic space, and management of medical records to health information. Whereas the second role is the role of the medical record as the staff at health care facilities. As a medical record required by their professional organizations to be able to perform functions in accordance with the seven competencies. The seven competencies are:
1. Classification and Codification of Diseases, Problems related to health and Medical Measures
2. Legal & Ethical Aspects of Professional
3. Medical Record Management & Health Information
4. Quality of Medical Record Keeping
5. Health Statistics
6. Medical Record Management Unit
7. Professional Partnership
This means that as a medical records staff at the unit expected to be able to perform its function of Classification and Codification of Diseases, Problems related to health and to the Partnership Action Medical Profession.