Rekam Medis

Medical record is a file that contains records and documents, among others, the identity of patients, the results of the 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 in accordance with regulations berlaku.data-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 palayanan.