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Tugas Medical record

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Tugas Medical record

  1. 1. Medical Record Dewi Windaningrum Presented by Jessica Arisa Diestananda
  2. 2. What is medical record? Medical record is both written or recorded information about identity, anamnesis, laboratory report, diagnosis, and all services and medical treatments given to the inpatient, outpatient or emergency patient .(Dirjen Pelayanan Medis, 2006)
  3. 3. What is medical record? Medical record is a document which contain patient identification data, examination record, treatment, medical procedures and other services that have been given to the patient. (PMK 24 Tahun 2022)
  4. 4. nction of medical record Medical records can be used as legal evidence to protect patients, providers (doctors, nurses and staff) or other health services as well as managers and owners of health facilities against law. A medical record file has administrative value, because its contents involve actions based on authority and responsibility as medical and paramedic personnel in achieving health service goals. A medical record file has financial value because its contents can be used as material for determining the cost of paying for services at health care facilities. Without evidence of action/service records, payments cannot be accounted for. Suatu berkas rekam medis mempunyai nilai penelitian, karena isinya mengandung data/informasi yang dapat digunakan sebagai aspek penelitian dan pengembangan ilmu pengetahuan di bidang kesehatan A medical record file has educational value, because its contents involve data/information about the chronological development of medical record services and activities provided to patients. This information can be used as teaching material. A medical record file has documentation value, because its contents become a source of memory that must be documented and used as material for accountability and hospital reports.
  5. 5. Philosophy of Medical Record The data in the medical record must be correct and not manipulated. The data in the medical record can be a source of information for those who need it. The data in the medical record must be accountable for its validity.
  6. 6. Definition of Medical Record File A medical record file includes identification information, patient’s medical history, medication history, treatment history and medical directives. A medical record file includes a variety of types of "notes" entered over time by doctors, dentist, healthcare professionals, therapist, nutritionist etc. A medical record file is kept in the medical record room by medical record staff who has been sworn to secrecy. PMK No 269 Tahun 2008
  7. 7. Content of Medical Record File Medical record need to at least contain of:  Patient’s identity  Results of Physical and supporting examinations  Diagnosis, treatments and follow-up plan of health services  Name and signature of the health care professionals PMK No 24 Tahun 2022
  8. 8. Content of Medical Record File Electronic medical record contains of:  Administrative documentation At least it has to have registration documentation  Clinical documentation Contains all documentation of health services given to the patients when they visited health facility PMK No 24 Tahun 2022
  9. 9. Medical Record Flow Patient come to the health care facility Patient doing registration at the registration counter Medical record staff takes medical record from medical record room for old patients Patient wait to be called at the designated area Medical record is sent to designated outpatient ward by medical record staff Patient’s receive health care services after the health care professional receive patient’s medical record Patient’s diagnosis is written by health care professional Patient goes home Medical record goes back to medical record room Medical record staff does: assembling, coding, indexing Medical record staff does daily report Medical record staff does filing which means storing the medical record Medical record staff gives new medical record number for new patients
  10. 10. Questions? Which Permenkes use in the presentation for the definition of medical record? a. PMK 21 Th 2022 b. PMK 22 Th 2022 What is the philsophy of medical record? a. Inquisitive b. Informative c. PMK 23 Th 2022 d. PMK 24 Th 2022 c. Insensitive d. Imperative
  11. 11. Questions? What does F stand for in ALFRED? a. Function b. Feasibility What does L stand for in ALFRED? a. Liability b. Legal c. Farce d. Financial c. Liason d. Language
  12. 12. Questions? In the medical record flow chart, what does medical record staff do if the patient is new? a. Give new medical record number b. Give new medical record point c. Give new medical record rate d. Give new medical record amount Which one of the following is NOT medical record staff’s job? a. Coding b. Filing c. Indexing d. Shipping
  13. 13. CREDITS: This presentation template was created by Slidesgo, and includes icons by Flaticon, and infographics & images by Freepik Thank you!

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