{"id":51,"date":"2024-05-31T10:21:32","date_gmt":"2024-05-31T10:21:32","guid":{"rendered":"https:\/\/gretha.my.id\/rme\/?p=51"},"modified":"2024-06-01T11:18:39","modified_gmt":"2024-06-01T11:18:39","slug":"isi-rekam-medis-terdiri-atas-apa-saja","status":"publish","type":"post","link":"https:\/\/gretha.my.id\/rme\/isi-rekam-medis-terdiri-atas-apa-saja\/","title":{"rendered":"Isi Rekam Medis terdiri atas apa saja ?"},"content":{"rendered":"<p data-sourcepos=\"1:1-1:135\"><span style=\"color: #000000;\"><button id=\"listenButton1\" class=\"responsivevoice-button\" type=\"button\" value=\"Play\" title=\"ResponsiveVoice Tap to Start\/Stop Speech\"><span>&#128266; Baca &amp; Dengarkan<\/span><\/button>\n        <script>\n            listenButton1.onclick = function(){\n                if(responsiveVoice.isPlaying()){\n                    responsiveVoice.cancel();\n                }else{\n                    responsiveVoice.speak(\"Berdasarkan Peraturan Menteri Kesehatan Republik Indonesia Nomor 24 Tahun 2022 Tentang Rekam Medis, isi Rekam Medis Elektronik (RME) terdiri atas: 1. Data Identitas Pasien: Nama lengkap Nomor Rekam Medis Tanggal lahir Jenis kelamin Alamat Nomor telepon Pekerjaan Status pernikahan Nama, alamat, dan nomor telepon penanggung jawab pasien Asuransi kesehatan pasien 2. Data Anamnesis: Keluhan utama pasien Riwayat kesehatan pasien Riwayat penyakit keluarga Riwayat alergi obat Riwayat penggunaan obat Riwayat operasi Riwayat imunisasi Riwayat sosial dan lingkungan 3. Data Pemeriksaan Fisik: Tanda-tanda vital Hasil pemeriksaan fisik sistematis Hasil pemeriksaan penunjang diagnostik Diagnosis Rencana tatalaksana Prognosis 4. Data Catatan Tindakan Medis: Tindakan medis yang dilakukan Obat-obatan yang diberikan Transfusi darah Terapi non-medikamentosa Pendidikan kesehatan Konsultasi dengan dokter lain 5. Data Catatan Keperawatan: Asuhan keperawatan yang diberikan Kondisi pasien Respon pasien terhadap asuhan keperawatan Masalah keperawatan Tujuan keperawatan Intervensi keperawatan Evaluasi keperawatan 6. Data Catatan Rehabilitasi Medis: Tujuan rehabilitasi medis Rencana rehabilitasi medis Latihan fisik Terapi okupasi Terapi wicara Terapi psikologis Edukasi pasien 7. Data Catatan Lain: Informed consent Penolakan tindakan medis Catatan konsul Catatan alergi obat Catatan mediasi Catatan autopsi Catatan lainnya yang dianggap perlu Penting untuk dicatat: Isi Rekam Medis Elektronik dapat berbeda-beda tergantung pada jenis penyakit, kondisi pasien, dan jenis pelayanan kesehatan yang diberikan. Tenaga kesehatan yang mencatat informasi dalam Rekam Medis Elektronik harus memiliki kewenangan untuk melakukannya. Informasi dalam Rekam Medis Elektronik harus lengkap, akurat, dan terkini.\", \"Indonesian Female\");\n                }\n            };\n        <\/script>\n    <\/span><\/p>\n<p class=\"first-token\" data-sourcepos=\"1:1-1:135\"><span style=\"color: #000000;\">Berdasarkan <strong>Peraturan Menteri Kesehatan Republik Indonesia Nomor 24 Tahun 2022 Tentang Rekam Medis<\/strong>, isi Rekam Medis Elektronik (RME) <strong>terdiri atas<\/strong>:<\/span><\/p>\n<p data-sourcepos=\"3:1-3:29\"><span style=\"color: #000000;\"><strong>1. Data Identitas Pasien<\/strong>:<\/span><\/p>\n<ul data-sourcepos=\"5:1-7:15\">\n<li data-sourcepos=\"5:1-5:14\"><span style=\"color: #000000;\">Nama lengkap<\/span><\/li>\n<li data-sourcepos=\"6:1-6:19\"><span style=\"color: #000000;\">Nomor Rekam Medis<\/span><\/li>\n<li data-sourcepos=\"7:1-7:15\"><span style=\"color: #000000;\">Tanggal lahir<\/span><\/li>\n<li data-sourcepos=\"8:1-8:15\"><span style=\"color: #000000;\">Jenis kelamin<\/span><\/li>\n<li data-sourcepos=\"9:1-9:8\"><span style=\"color: #000000;\">Alamat<\/span><\/li>\n<li data-sourcepos=\"10:1-10:15\"><span style=\"color: #000000;\">Nomor telepon<\/span><\/li>\n<li data-sourcepos=\"11:1-11:11\"><span style=\"color: #000000;\">Pekerjaan<\/span><\/li>\n<li data-sourcepos=\"12:1-12:19\"><span style=\"color: #000000;\">Status pernikahan<\/span><\/li>\n<li data-sourcepos=\"13:1-13:50\"><span style=\"color: #000000;\">Nama, alamat, dan nomor telepon penanggung jawab pasien<\/span><\/li>\n<li data-sourcepos=\"14:1-15:0\"><span style=\"color: #000000;\">Asuransi kesehatan pasien<\/span><\/li>\n<\/ul>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-81 size-large\" src=\"https:\/\/gretha.my.id\/rme\/wp-content\/uploads\/2024\/05\/form-input-pasien-norm-1024x470.png\" alt=\"\" width=\"1024\" height=\"470\" srcset=\"https:\/\/gretha.my.id\/rme\/wp-content\/uploads\/2024\/05\/form-input-pasien-norm-1024x470.png 1024w, https:\/\/gretha.my.id\/rme\/wp-content\/uploads\/2024\/05\/form-input-pasien-norm-300x138.png 300w, https:\/\/gretha.my.id\/rme\/wp-content\/uploads\/2024\/05\/form-input-pasien-norm-768x353.png 768w, https:\/\/gretha.my.id\/rme\/wp-content\/uploads\/2024\/05\/form-input-pasien-norm.png 1348w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/p>\n<p>&nbsp;<\/p>\n<p data-sourcepos=\"16:1-16:22\"><span style=\"color: #000000;\"><strong>2. Data Anamnesis<\/strong>:<\/span><\/p>\n<ul data-sourcepos=\"18:1-20:9\">\n<li data-sourcepos=\"18:1-18:22\"><span style=\"color: #000000;\">Keluhan utama pasien<\/span><\/li>\n<li data-sourcepos=\"19:1-19:26\"><span style=\"color: #000000;\">Riwayat kesehatan pasien<\/span><\/li>\n<li data-sourcepos=\"20:1-20:9\"><span style=\"color: #000000;\">Riwayat penyakit keluarga<\/span><\/li>\n<li data-sourcepos=\"21:1-21:21\"><span style=\"color: #000000;\">Riwayat alergi obat<\/span><\/li>\n<li data-sourcepos=\"22:1-22:25\"><span style=\"color: #000000;\">Riwayat penggunaan obat<\/span><\/li>\n<li data-sourcepos=\"23:1-23:17\"><span style=\"color: #000000;\">Riwayat operasi<\/span><\/li>\n<li data-sourcepos=\"24:1-24:19\"><span style=\"color: #000000;\">Riwayat imunisasi<\/span><\/li>\n<li data-sourcepos=\"25:1-26:0\"><span style=\"color: #000000;\">Riwayat sosial dan lingkungan<\/span><\/li>\n<\/ul>\n<p data-sourcepos=\"27:1-27:30\"><span style=\"color: #000000;\"><strong>3. Data Pemeriksaan Fisik<\/strong>:<\/span><\/p>\n<ul data-sourcepos=\"29:1-35:0\">\n<li data-sourcepos=\"29:1-29:19\"><span style=\"color: #000000;\">Tanda-tanda vital<\/span><\/li>\n<li data-sourcepos=\"30:1-30:36\"><span style=\"color: #000000;\">Hasil pemeriksaan fisik sistematis<\/span><\/li>\n<li data-sourcepos=\"31:1-31:40\"><span style=\"color: #000000;\">Hasil pemeriksaan penunjang diagnostik<\/span><\/li>\n<li data-sourcepos=\"32:1-32:11\"><span style=\"color: #000000;\">Diagnosis<\/span><\/li>\n<li data-sourcepos=\"33:1-33:21\"><span style=\"color: #000000;\">Rencana tatalaksana<\/span><\/li>\n<li data-sourcepos=\"34:1-35:0\"><span style=\"color: #000000;\">Prognosis<\/span><\/li>\n<\/ul>\n<p data-sourcepos=\"36:1-36:35\"><span style=\"color: #000000;\"><strong>4. Data Catatan Tindakan Medis<\/strong>:<\/span><\/p>\n<ul data-sourcepos=\"38:1-44:0\">\n<li data-sourcepos=\"38:1-38:31\"><span style=\"color: #000000;\">Tindakan medis yang dilakukan<\/span><\/li>\n<li data-sourcepos=\"39:1-39:28\"><span style=\"color: #000000;\">Obat-obatan yang diberikan<\/span><\/li>\n<li data-sourcepos=\"40:1-40:17\"><span style=\"color: #000000;\">Transfusi darah<\/span><\/li>\n<li data-sourcepos=\"41:1-41:26\"><span style=\"color: #000000;\">Terapi non-medikamentosa<\/span><\/li>\n<li data-sourcepos=\"42:1-42:22\"><span style=\"color: #000000;\">Pendidikan kesehatan<\/span><\/li>\n<li data-sourcepos=\"43:1-44:0\"><span style=\"color: #000000;\">Konsultasi dengan dokter lain<\/span><\/li>\n<\/ul>\n<p data-sourcepos=\"45:1-45:32\"><span style=\"color: #000000;\"><strong>5. Data Catatan Keperawatan<\/strong>:<\/span><\/p>\n<ul data-sourcepos=\"47:1-54:0\">\n<li data-sourcepos=\"47:1-47:35\"><span style=\"color: #000000;\">Asuhan keperawatan yang diberikan<\/span><\/li>\n<li data-sourcepos=\"48:1-48:16\"><span style=\"color: #000000;\">Kondisi pasien<\/span><\/li>\n<li data-sourcepos=\"49:1-49:43\"><span style=\"color: #000000;\">Respon pasien terhadap asuhan keperawatan<\/span><\/li>\n<li data-sourcepos=\"50:1-50:21\"><span style=\"color: #000000;\">Masalah keperawatan<\/span><\/li>\n<li data-sourcepos=\"51:1-51:20\"><span style=\"color: #000000;\">Tujuan keperawatan<\/span><\/li>\n<li data-sourcepos=\"52:1-52:24\"><span style=\"color: #000000;\">Intervensi keperawatan<\/span><\/li>\n<li data-sourcepos=\"53:1-54:0\"><span style=\"color: #000000;\">Evaluasi keperawatan<\/span><\/li>\n<\/ul>\n<p data-sourcepos=\"55:1-55:39\"><span style=\"color: #000000;\"><strong>6. Data Catatan Rehabilitasi Medis<\/strong>:<\/span><\/p>\n<ul data-sourcepos=\"57:1-64:0\">\n<li data-sourcepos=\"57:1-57:27\"><span style=\"color: #000000;\">Tujuan rehabilitasi medis<\/span><\/li>\n<li data-sourcepos=\"58:1-58:28\"><span style=\"color: #000000;\">Rencana rehabilitasi medis<\/span><\/li>\n<li data-sourcepos=\"59:1-59:15\"><span style=\"color: #000000;\">Latihan fisik<\/span><\/li>\n<li data-sourcepos=\"60:1-60:16\"><span style=\"color: #000000;\">Terapi okupasi<\/span><\/li>\n<li data-sourcepos=\"61:1-61:15\"><span style=\"color: #000000;\">Terapi wicara<\/span><\/li>\n<li data-sourcepos=\"62:1-62:19\"><span style=\"color: #000000;\">Terapi psikologis<\/span><\/li>\n<li data-sourcepos=\"63:1-64:0\"><span style=\"color: #000000;\">Edukasi pasien<\/span><\/li>\n<\/ul>\n<p data-sourcepos=\"65:1-65:25\"><span style=\"color: #000000;\"><strong>7. Data Catatan Lain<\/strong>:<\/span><\/p>\n<ul data-sourcepos=\"67:1-74:0\">\n<li data-sourcepos=\"67:1-67:18\"><span style=\"color: #000000;\">Informed consent<\/span><\/li>\n<li data-sourcepos=\"68:1-68:26\"><span style=\"color: #000000;\">Penolakan tindakan medis<\/span><\/li>\n<li data-sourcepos=\"69:1-69:16\"><span style=\"color: #000000;\">Catatan konsul<\/span><\/li>\n<li data-sourcepos=\"70:1-70:21\"><span style=\"color: #000000;\">Catatan alergi obat<\/span><\/li>\n<li data-sourcepos=\"71:1-71:17\"><span style=\"color: #000000;\">Catatan mediasi<\/span><\/li>\n<li data-sourcepos=\"72:1-72:17\"><span style=\"color: #000000;\">Catatan autopsi<\/span><\/li>\n<li data-sourcepos=\"73:1-74:0\"><span style=\"color: #000000;\">Catatan lainnya yang dianggap perlu<\/span><\/li>\n<\/ul>\n<p data-sourcepos=\"75:1-75:26\"><span style=\"color: #000000;\"><strong>Penting untuk dicatat<\/strong>:<\/span><\/p>\n<ul data-sourcepos=\"77:1-77:144\">\n<li data-sourcepos=\"77:1-77:144\"><span style=\"color: #000000;\">Isi Rekam Medis Elektronik <strong>dapat berbeda-beda<\/strong> tergantung pada jenis penyakit, kondisi pasien, dan jenis pelayanan kesehatan yang diberikan.<\/span><\/li>\n<li data-sourcepos=\"78:1-78:121\"><span style=\"color: #000000;\">Tenaga kesehatan yang mencatat informasi dalam Rekam Medis Elektronik <strong>harus memiliki kewenangan<\/strong> untuk melakukannya.<\/span><\/li>\n<li data-sourcepos=\"79:1-80:0\"><span style=\"color: #000000;\">Informasi dalam Rekam Medis Elektronik <strong>harus lengkap, akurat, dan terkini<\/strong>.<\/span><\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Berdasarkan Peraturan Menteri Kesehatan Republik Indonesia Nomor 24 Tahun 2022 Tentang Rekam Medis, isi Rekam [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":56,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5],"tags":[],"class_list":["post-51","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-rme"],"amp_enabled":true,"_links":{"self":[{"href":"https:\/\/gretha.my.id\/rme\/wp-json\/wp\/v2\/posts\/51","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/gretha.my.id\/rme\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/gretha.my.id\/rme\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/gretha.my.id\/rme\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/gretha.my.id\/rme\/wp-json\/wp\/v2\/comments?post=51"}],"version-history":[{"count":4,"href":"https:\/\/gretha.my.id\/rme\/wp-json\/wp\/v2\/posts\/51\/revisions"}],"predecessor-version":[{"id":98,"href":"https:\/\/gretha.my.id\/rme\/wp-json\/wp\/v2\/posts\/51\/revisions\/98"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/gretha.my.id\/rme\/wp-json\/wp\/v2\/media\/56"}],"wp:attachment":[{"href":"https:\/\/gretha.my.id\/rme\/wp-json\/wp\/v2\/media?parent=51"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/gretha.my.id\/rme\/wp-json\/wp\/v2\/categories?post=51"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/gretha.my.id\/rme\/wp-json\/wp\/v2\/tags?post=51"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}