web 2.0

Sabtu, 13 Februari 2016

Jual tanah strategis daerah jember dekat daerah kampus

 Jl. Koptu Berlian daerah kaliurang lokasi dekat kampus cocok buat kos2 an dekat ama pembangunan universitas arum sabil luas tanah 9x13 SHM, Harga 175500000 bisa nego lokasi jember kota hp: 085100050087

Read More..

Rabu, 19 September 2012


KNC (Kejadian Nyaris Cedera) dan KTD (Kejadian Tidak Diharapkan) merupakan kumpulan dari KLPCM kejadian KNC terjadi pada pasien tetapi ngak ada resikonya pada pasien tersebut, sehingga tidak memperlukan audit medis yang berhubungan dengan pelayanan medis, sedangkan KTD kejadian yang ada resikonya pada pihak pasien tersebut,, contohnya malpraktek sehingga memperlukan audit medis,,,, bersambung...... Read More..

Senin, 27 Februari 2012

Perkuliahan EHR 1

-menerangkan SIK (sistem informasi kesehatan), Impelementasi sistem, Aspek hukum EhR dan keamanan sistem.
-sistem suatu susunan saling berhubungan untuk mencapai tujuan. sistem terdiri dari:
input proses output terdapat kendali atau kontrol
-sim kumpulan subsistem yg melaksanakan fungsi2 tertentu dalam organisasi. 
-desentralisasi pelaporan rumah sakitnya..... dinkes kab...
-Sik meliputi pelaporan data ekternal sama pelaporan data internal suatu rumah sakit. berdasarkan kab, prov, pusat.
-model SIM
manajemen kesetan---> Bank Data---> data indikator, informasi---> publikasi, kemsan khusus, angaran, data sekunder, pelaporan....
-masalah utama di sim ;
pelaporan belum terkoordinasi
sebagian daerah belum memiliki SIM
pemanfaatan Sim belum optimal
pemanfaatan data dan sim belum imbang
pemanfaatan TI belum optimal
dana masih kurang untuk sim
belum banyk tenaga purna waktu.
- pendayaguanan pelaporan data penyakit pada puskesmas kurang optimal dalm mengolah data sehingga pengambilan keputusan kurang optimal....

Read More..

Rabu, 21 Desember 2011

Informend Consent

A. Informend Consent (IC)

Making this form refers to the regulation of health ministers of Approval No. 585/MENKES/PER/IX/1989 Medical Measures and the decision of the Director General of Medical Services HK. on Guidelines for Approval of Medical Action (Consent Informend) dated April 21, 1999. Decision on guidelines for Action Medical Consent (Informed Consent):


1. Consent of Medicine or Dentistry (Informed Consent) isa. Consent given by patients or their families on the basis of medical explanation of the action to be taken against the patient's proficiency level.b. Consent of patients or families who legitimately represents the plan of action Dental medicine or medicine proposed by the physician or dentist, after receiving sufficient information to make the approval.c. Unilateral declaration of the patient and not the agreement between the patients with a physician or dentist, so it may be withdrawn at any time.
d. Sekaligud process is the result of an effective communication Atara patients with a doctor or dentist, and not merely signing a consent form.2. The act of medicine or dentistry is an act of medicine or dentistry performed on patients for the purpose of preventive, diagnostic, therapeutic or rehabilitative3. Medical action is: the action is performed on patients in the form of a diagnostic or therapeutic invasive Included here is the act of direct action that may affect the integrity of the network (eg: Slicing, stabbing, or cutting tissue)4. The act of medicine or dentistry that contain high risk is the act of medicine or dentistry that with a certain probability of resulting in death. or disability (loss of or damage to the function of certain organs) such as invasive surgery or certain actions.5. Invasive action is the act of medicine or dentistry that can directly affect the integrity of the patient's body tissues.6. Guardian is a person who is legally considered to represent the legitimate interests of others who are not competent (in this case the patient is not komputen)7. Immediate family is a husband or wife, parent or child of a legitimate and siblings.8. Pengampu a person or body who set the court as a party representing the interests of a particular person (in this case patients) are declared to be under guardianship (curetale).9. Competent is competent to receive information, understand, analyze, and use it in making the approval or rejection of medicine or dentistry action.
1. All medical acts to be performed on patients must be approved either in writing or verbally.2. Measures approved orally:a. All patients in the clinic (by giving the examination / oral on what would be done on patients such as: will an injection point injection and so on)b. All Pasaien in the ER that require action injection, kateresasi, post infusion, gastric sonde pairs, pairs of gibs and others (who are not at high risk)c. All patients in the Installation Medical Support:
1. Laboratory examination requires a:- Take blood intravenously.- Take blood for Hb dal another - another.
2. With all inpatients that require no high-risk acts such as:- Injecting- Connect the infusion- Connect the hose ulcer- Replace the rectal tube- Replace the catheter and the other - other3. approval was given after the patient received information about necessity adekwat relevant medical actions and risks that could bring.4. Method of delivery and content of information must be adjusted to the level - the level of education as well as the patient's condition or situation, so that the recipient of information really - really understand it.5. Persetujan writing signed by the right to give consent should be made to any medical act which contains a high risk. While the medical actions that do not contain a high risk of a written consent is not required and just enough verbal agreement.6. Memerllukan Persetuan the written approval include:a. Supporting medical Dinstalasi.1.Radiologi.


- Ultrasound and other - other
2. Laboratory: cerebro spinal examination.a. Patients seeking treatment at the ER who require surgery of small, medium, large and specialty.b. Patients in the Inpatient medical measures that will be operating medium, large and specialized7. Patients who underwent a custody or sentence has the same rights as other patients, thereby consent to the examination of treatment / surgery, must be obtained pursuant to paragraph - paragraph of Article (2) above.INFORMATION1. Physician or dentist or care giver perpetrator inspection / action is obliged to provide information about medical actions that will be given to the patient, whether asked or not asked to ensure that consent is obtained for right and proper.2. Your doctor or dentist can mendelagasikan process of providing information and receiving approval of the action, but remains responsible for the delegation.3. Physician or dentist will provide information and receive patient consent on behalf of another physician or dentist, the doctor / dentist should be sure bahwea himself able to answer fully any questions asked of patients regarding the actions to be performed on patients to ensure that consent are made correctly and feasible;4. Information supplied as complete - complete, except when the physician considers that the information can be detrimental to the interests of patient health or patient refuses to be informed. In these circumstances a doctor with the consent of the patient can provide information to the next of kin to the other accompanied by a nurse as a witness.PROCEDURES FOR INFORMATION
1. Information provided includes diagnosis and procedure of medical action, the purpose of the action taken, other action alternatives and the risks, the risks and complications that may occur and the prognosis of the action taken.2. Information given verbally.3. Information should be done honestly and correctly unless your doctor considers that it can be detrimental to the interests of the patient's health. With the approval of concerned patients, doctors can provide information to the closest relatives of these patients.4. Information should also be given if there is possible expansion of operations. The expansion of operations that can not be expected to do to save lives of patients. In these circumstances the operation is done after the expansion of physician must provide information to patients or their families.
1. Doctors operators: In this surgery (surgery) or other invasive techniques, information must be provided by a doctor who will perform opearasi itself;2. In certain circumstances where no physician operator, information must be provided by another physician with knowledge or instructions the doctor in charge;3. Your doctor or nurse; in terms of action rather than surgery (surgery) and the action is not invasive laninya, information can be given by another doctor or nurse with the knowledge or instructions the doctor in charge.
1. Peretujuan given by adult patients (aged more than 21 years old or married) are arriving in a state of conscious and mentally healthy.2. Diberkan consent by a parent / guardian / curetale for;a. Adult patients who suffer from mental disordersb. Adult patients who were brought forgiveness (curetale)c. Approval is given by the next of kin or the landlord for the patient was taken 21 years or do not have a parent / guardian or parent / guardian is absent3. Not required approval from anyone to:a. Unconscious patient / pinsan and not accompanied by immediate family and medical arriving in a state of emergency and or medical emergency requiring immediate action for its interestsb. Medical actions to be undertaken in accordance with government programs in which medical measures to the benefit of society.

1. physician / dentist is responsible for the implementation of the provisions concerning the approval of the actions of medical / dental2. participate bertnggung responsible for granting approval of medical acts performed in
1. Refusal of medical omissions or conduct medical examinations necessary to check again whether the patient has understood the information about the patient's condition, action or treatment, serata all desires and their side effects;2. If the patient still refuses, as paragraph 1 for the actions of the medical examination, the patient or guardian / next of kin / curetale refusal to sign a form of medical action3. Omissions as a result of paragraph 2 of the act of rejection stating bertanggun full responsibility for any consequences that may arise as a result of the
Against the doctor or dentist who requires medical or dental action without the consent of the patient or family may be imposed under criminal law, Civil Law, Discipline by MKDKI.
1. Physician or dentist, students in conducting research using humans as subjects must obtain consent from patients who become research subjects.2. Criteria - specific criteria to be able to use human beings as research subjects is determined by the medical committee;3. The research conducted does not conflict with the interests of the patient, knowing that the study subjects were followed keterlibatanya research and voluntarily;Types of actions other medicine or dentistry, as article 2, paragraph 2 and may be proposed by each - each Functional Medical Staff and coordinated by the Medical Committee.
Read More..

Minggu, 18 Desember 2011


A. Acceptance of patients:    
a. Patients who can wait:        
- Patients who come to the outpatient department is not        
- Patients who come in a state of emergency. 
B. According to the type of arrival of patients can be divided into:    
a. New patients: patients who come for treatment the first time   
b. Old patients: patients who had previously come to the hospital for treatment
C. Patient arrival to the hospital may occur because:      
a. Submitted by practicing physicians outside the hospital.      
b. Posted by another hospital, clinic or other types of health services.      
c. Come of their own accord. 
D. OutpatientsOutpatient service activities can be divided into two, namely:a. New patients: each new patient getting treatment card filled with medical record numbers, the identity of the patient who must be brought to the next visit to the same hospital. Outpatient medical record section is written to the outpatient register books containing patient identification data, etc.. Book register is used as a basis for making the Main Index Patient Card. Medical record file is sent back to goto the outpatient medical record except in patients who should be treated. In patients treated mediknya record also included treatment chamber. 
b. Old patients: by presenting the card can be treated outpatient medical records resolved, then the patient is sent to Poly outpatient unit, but if treatment outside of working hours created a new medical records with the same number.
 E. Emergency PatientsEmergency patient reception is opened 24 hours. Here patients are helped first, and completing paperwork. After getting enough service, there are several possibilities of patients:- Patients go home- The patient was referred / other hospital- Patients should be hospitalizedIf the patient is checked out for a second time and so it is quite RM existing outpatient forwarded, but when medical treatment outside of working hours created a new medical records with the same number. Read More..


A.     Penerimaan pasien :
a.       Pasien yang dapat menunggu :
-         Pasien berobat jalan yang datang dengan tidak gawat
-         Pasien yang datang  dalam keadaan gawat.
B.     Menurut jenis kedatangannya pasien dapat dibedakan menjadi :
a.       Pasien baru     : pasien yang datang pertama kali untuk berobat
b.      Pasien lama   : pasien yang pernah datang sebelumnya ke rumah sakit untuk berobat
C.     Kedatangan pasien kerumah sakit dapat terjadi karena :
a.       Dikirim oleh dokter praktek di luar rumah sakit.
b.      Dikirim oleh RS lain, puskesmas atau jenis pelayanan kesehatan lainnya.
c.       Datang atas kemauan sendiri.
D.     Pasien rawat jalan
Kegiatan pelayanan rawat jalan dapat dibedakan menjadi 2 yaitu :
a.       Pasien baru : setiap pasien baru mendapatkan kartu berobat yang diisi dengan nomor  rekam medik, identitas pasien yang harus dibawa pada kunjungan berikutnya ke rumah sakit yang sama. Dibagian rekam medik rawat jalan ditulis ke buku register rawat jalan berisikan data identitas pasien dll. Buku register ini digunakan sebagai dasar sebagai pembuatan Kartu Indeks Utama Pasien. Berkas rekam medik tersebut dikirim kembali kebagian rekam medik  rawat jalan kecuali pada pasien yang harus dirawat. Pada pasien yang dirawat diikut sertakan juga rekam mediknya keruang perawatan.
b.      Pasien lama : dengan menunjukan kartu berobat dapat dicarikan rekam medik rawat jalan, kemudian pasien dikirimkan ke Poli unit rawat jalan, tetapi bila berobat diluar jam kerja  dibuatkan rekam medik baru dengan nomer sama.
E.      Pasien Gawat Darurat
Tempat penerimaan pasien Gawat darurat dibuka 24 jam. Disini pasien ditolong terlebih dulu, baru menyelesaikan administrasinya. Setelah mendapatkan pelayanan cukup, ada beberapa kemungkinan pasien :
-         Pasien langsung pulang
-         Pasien dirujuk/kerumah sakit lain
-         Pasien harus dirawat inap
Bila pasien memeriksakan diri untuk kedua kali dan seterusnya maka cukup RM rawat jalan yang sudah ada diteruskan, tetapi bila berobat diluar jam kerja  dibuatkan rekam medik baru dengan nomer sama.
Read More..

Kamis, 26 Mei 2011

Peminjaman, Pengamanan dan Kerahasiaan Rekam Medis

A. Peminjaman berkas rekam medis

Ketentuan peminjaman berkas rekam medis merujuk pada Permenkes 749a/Men Kes/per/XII/1989 tentang Medical Record, bahwa yang berhak meminjam berkas rekam medis hanya dokter yang merawat. Secara umum peminjaman rekam medis dibagi menjadi 2 ( dua ) yaitu pinjaman rutin dan tidak rutin.

Peminjaman rutin adalah peminjaman berkas rekam medis oleh dokter dikarenakan pasien yang memiliki berkas tersebut memerlukan atau sedang mendapatkan perawatan di unit pelayanan.

Peminjaman tidak rutin adalah peminjaman berkas rekam medis oleh tenaga kesehatan atau dokter untuk keperluan penelitian, makalah atau sejenisnya . ketentuan mengenai peminjaman ini dengan ketentuan sebagai berikut :

• Semua berkas rekam medis yang keluar dari ruangan rekam medis wajib dicatat pada tracer
• Semua berkas rekam medis rawat jalan harus kembali dalam waktu 1X24 jam, diluar ketentuan tersebut 
perawat/dokter yang masih membutuhkan rekam medis, wajib memberitahu kepada petugas rekam medis pada rawat jalan
• Berkas rekam medis rawat inap harus dikembalikan ke unit rekam medis 2X24 jam setelah pasien pulang
• Peminjaman rekam medis untuk keperluan riset, penelitian dilakukan di unit rekam medik

B. Pengambilan berkas rekam medis dari rak penyimpanan

Pengambilan kembali dokumen rekam medis atau retrivel adalah kegiatan pengambilan berkas rekam medis dirak berdasarkan permintaan (pasien yang datang untuk berobat atau untuk mendapatkan pelayanan kesehatan lainnya.

C. Pengiriman berkas rekam medis 

Setelah petugas mendaftar pasien rawat jalan kemudian memberitahukan pasien untuk menunggu di poli yang di tuju, serta petugas pendaftaran mengambil dibagian filling untuk mencari Rekam medis rawat jalan yang dimaksud (bila penderita kunjungan ulang) Kemudian petugas pendaftaran mengantar berkas Rekam Medis rawat jalan kunjungan ulang untuk diantar kepoli tujuan..

Bila kunjungan baru maka petugas pendaftaran langsung menganamnese pasien / keluarga untuk mengisi data identitas penderita yang ada pada Rekam Medis rawat jalan. Selanjutnya Rekam Medis rawat jalan tersebut diberikan kepada penderita untuk dibawa dan diserahkan kepada poli yang dimaksud.

D. Pengembalian berkas rekam medis

Dokumen rekam medis bersifat rahasia, (PP No. Tahun 1966) seorang yang menerima/meminjam rekam medis berkewajiban untuk menjaganya dalam keadaan baik dan menyerahkan kepada petugas RM. Untuk peminjaman dari UGD dan Rawat Inap berlaku jam pengembalian

E. Peraturan dan tata tertib pengamanan berkas rekam medis

Sebagaimana yang tertuang dalam Permenkes 749a / Menkes / PER / XIII/1989 pasal 10, mengatakan bahwa berkas RM milik rumah sakit dan isinya milik pasien. Dengan demikian sarana pelayanan kesehatan bertanggungjawab menjaga kerahasiaan dan keamanan rekam medis. Untuk mewujudkan terjaminnya kerahasiaan dan keamanan rekam medis.

F. Kerahasiaan informasi dalam berkas rekam medis

Rekam medis merupakan alat komunikasi antara dokter atau tenaga medis lainnya, yang turut ambil bagian dalam usaha memberikan pelayanan pengobatan atau perawatan kepada pasien. Karena itu catatan-catatan medis yang ada di dalam dokumen rekam medis merupakan data yang mempunyai nilai dalam pelayanan kesehatan berkelanjutan. Pemberian informasi diatur dalam peraturan pemerintah No. 10 tahun 1996.
Read More..