PROSEDUR PELAYANAN REKAM MEDIS

Nomor : /PKM-CBL/SOP/ /2016

Terbit ke :
SOP No.Revisi :
Tg.!iber"k# :
$""m"% :

M. (MSOR
&PT P#skesm"s Cib"i#%g tt'

1. Pe%gerti"% Berk"s rek"m me'is mer#)"k"% *"t"t"% i%+om"si ,"%g "k#r"t te%t"%g
'"t" )"sie% ,"%g mei)#ti *"t"t"% i'e%tit"s )"sie% "%"m%esis
" %"m%esis )e%et#"%
+isik )er""%"% )e%,"kit )emeriks""% )e%#%"%g 'i"g%osis ti%'"k"%
me'is '"% )roses )e%gob"t"% ,"%g 'iberik"% ke)"'" )"sie%. %+orm"si
,"%g "'" )"'" berk"s rek"m me'is bersi+"t r""si" sei%gg" "r#s
'i"g" ke"m"%"% '"% ker""si""%%,".
2. T##"%
1. Te
Tertib
rtib "'mi%istr"
"'mi%istr"si
si '""m r"%gk" #)"," me%i%gk"tk"%
me%i%gk"tk"% k#"it"s
)e","%"% kese"t"% 'i P#skesm"s Cib"i#%g

2. Ters
rse'i
e'i"%,
"%,"" )e
)e'om
'om"%
"% b"
b"gi
gi )et#g"
)et#g"ss te
terk
rk"i
"itt 'e
'e%g"
%g"%
% ke
kegi
gi"t
"t"%
"%
)e%,im)"%"% / )e%ge#"r"% kemb"i berk"s rek"m me'is '"ri r"k
"t"# r#"%g )e%,im)"%"% berk"s rek"m me'is.

3. Me%"g" ke"m"%"% '"% ker""si""% berk"s rek"m me'is

4. Kebi"k"% 1. $"%," )et#g"s rek"m me'is ,"%g bere%"%g '"% ber"k m"s#k ke
r#"%g )e%,im)"%"% '"% me%g"mbi berk"s rek"m me'is.
2. Seti") i%+orm"
i%+orm"si
si b"ik
b"ik me'is m"#)#%
m"#)#% %o% me'is ,"%g
,"%g 'imiiki
'imiiki
oe P#skesm"s Cib"i#%g 'i"r"%g 'iseb"r#"sk"% oe )eg""i
P#skesm"s Cib"i#%g ke)"'" si")")#% b"ik se*"r" tert#is m"#)#%
is"% ke*#"i "t"s ii% Ke)"" P#skesm"s Cib"i#%g.

3. Re+ere%si SK Pe","%"% Rek"m Me'is

4. Prose'#r 1 Me%,i")k"% +orm#ir '"% *"t"t"% sert" %omor rek"m me'is ,"%g
'i)er#k"% #%t#k )e","%"%. 3orm#ir '"% *"t"t"% ,"%g )er#
'isi")k"% ,"it# :
a 3orm#ir-+orm#ir 'ok#me% rek"m me'is r""t ""% b"r#

,"%g te" 'iberi %omor rek"m me'is ,"it#

," it# +orm#ir rek"m
me'is ,"%g be#m berisi *"t"t"% )e","%"% )"sie% ,"%g "#.
b B#k# register )e%'"+t"r"% )"sie% r""t ""% ,"it# b#k# ,"%g
berisi *"t"t"% i'e%tit"s )"sie% seb"g"i *"t"t"% )e%'"+t"r"%.
c B#k# eks)e'isi ,"it# b#k# ,"%g 'ig#%"k"% #%t#k ser" terim"
'ok#me% rek"m me'is "g"r e"s si")" ,"%g me%erim"%,".
d K&P 4K"rt# %'eks &t"m" P"sie%5 ,"it# k"rt# i%'eks ,"%g
'ig#%"k"% seb"g"i )et#%#k )e%*"ri"% kemb"i i'e%tit"s
)"sie%.
e KB/KTPP 4K"rt# 'e%tit"s Berob"t/ K"rt# T"%'"
T"%'" Pe%ge%"
P"sie%5 ,"it# k"rt# i'e%tit"s )"sie% ,"%g 'iser"k"% ke)"'"
 )"sie% #%t#k 'ig#%"k"% kemb"i bi" '"t"%g berob"t "gi.
f Tr"*er ,"it# k"rt# ,"%g 'ig#%"k"% #%t#k )et#%#k
'ig#%"k%%," 4ke#"r%,"5 'ok#me% rek"m me'is '"ri r"k +ii%g
sei%gg" '")"t 'ig#%"k"% #%t#k )emi%"m"% 'ok#me% rek"m
me'is ke +ii%g.
g B#k# *"t"t"*% )e%gg#%""% %omor rek"m me'is ,"it# b#k#
,"%g berisi *"t"t"% )e%gg#%""% %omor rek"m me'is.
h K"r*is )e%'"+t"r"% )"sie%.
2 Me%"%,"k"% ke)"'" )"sie% ,"%g '"t"%g ")"k" s#'" )er%"
berob"t Bi" be#m ber"rti )"sie% b"r# '"% bi" s#'" ber"rti
)"sie% "m"
3 Pe","%"% ke)"'" )"sie% b"r# mei)#ti:
a Me%"%,"k"% i'e%tit"s )"sie% se*"r" e%gk") #%t#k 'i*"t"t

)"'" +orm#ir rek"m me'is )"sie% r""t ""% KB '"% K&P.
K&P.
b Me%,er"k"% KB ke)"'" )"sie% 'e%g"% )es"% #%t#k
memb"" kemb"i bi" '"t"%g berob"t berik#t%,".
c Me%,im)"% K&P ses#"i #r#t"% %omorek.
d Me%"%,"k"% ke#"% #t"m"%," g#%" mem#'"k"%
m"%g"r"k"% )"sie% ke )oiki%ik ,"%g ses#"i.
e Me%"%,"k"% ")"k" memb"" s#r"t r##k"%. Bi" memb"" :
f Tem)ek"%
Tem)ek"% )"'" +orm#ir rek"m me'is )"sie% r""t ""%.
g B"*" isi%," 'it##k"% ke)"'" 'okter si")" "t"# 'i"g%osis%,"
")" g#%" me%g"r"k"% )"sie% me%## ke )oiki%ik ,"%g
ses#"i.
h Mem)ersi"k"% )"sie% me%#%gg# 'i r#"%g t#%gg# )oiki%ik
,"%g ses#"i.
i Me%girimk"% 'ok#me% rek"m me'is ke )ooki%ik ,"%g
ses#"i 'e%g"% me%gg#%"k"% b#k# eks)e'isi.
4 Pe","%"% ke)"'" )"sie% "m" mei)#ti :
a. Me%"%,"k"% i'e%tit"s )"sie% se*"r" e%gk") #%t#k 'i*"t"t

)"'" +orm#ir rek"m me'is )"sie% r""t ""% KB '"%

K&P.
5 Sete" "kir )e","%"% kegi"t"%%," "'"" :
a Me%*"t"t i'e%tit"s )"'" b#k# register )e%'"+t"r"% )"sie%
) "sie%
r""t ""%.
b Me%*o*okk"% #m" )"sie% 'e%g"% #m" )e%'"+t"r"%
)"sie% r""t ""% 'e%g"% k"sir r""t ""%.
c Pe%gg#%""% %omor rek"m me'is "g"r ti'"k ter"'i '#)ik"si.
d Pe%gg#%""% +orm#ir rek"m me'is #%t#k )e%ge%'"i"%
)e%gg#%""% +orm#ir rek"m me'is.
e Merek")iti"si #m" k#%#%g"% )"sie% b"r# '"% "m" #%t#k
ke)er#"% st"tisti* )#skesm"s.

6. &%it terk"it 1. &%s#r Pim)i%"%.

2. BP Pemeriks""% #m#m
3. K(
 4. 7igi
5. &7!
6. PON8!
7. 7ii
8. %st""si R""t %")
7. !i"gr"m (ir
Me%,i")k"% +orm#ir '"% *"t"t"%
sert" %omor rek"m me'is ,"%g
'i)er#k"% #%t#k )e","%"%.
3orm#ir '"% *"t"t"% ,"%g )er#
'isi")k"%

+orm#ir 'ok#me% rek"m me'is

r""t ""% b"r# ,"%g te" 'iberi B#k#
%omor rek"m me'is ,"it# eks)e'isi
+orm#ir rek"m me'is ,"%g ,"it# b#k#
be#m berisi *"t"t"% )e","%"% ,"%g
"s
"sie
ie%
% "% " "#
#.. 'ig#%"k"%
#%t#k ser"
terim"
'ok#me%
B#k# register )e%'"+t"r"%
)"sie% r""t ""% ,"it# rek"m me'is
"g"r e"s
b#k# ,"%g berisi *"t"t"%
si")" ,"%g
i'e%tit"s )"sie% seb"g"i
me%erim"%,"
*"t"t"% )e%'"+t"r"%

Me%"%,"k"% ke)"'" )"sie%

k"rt# i%'eks ,"%g
,"%g '"t"%g ")"k" s#'"
'ig#%"k"% seb"g"i
)er%" berob"t Bi" be#m )et#%#k )e%*"ri"%
ber"rti )"sie% b"r# '"% bi"
bi" kemb"i i'e%tit"s
)"sie%
s#'" ber"rti )"sie% "m"

8. Rek"m"% istoris )er#b""%

No 9"%g
9"%g 'ir#b" si Per#b""% Tg.m#"i
'iber"k#k"%
 PROSEDUR PELAYANAN REKAM MEDIS

Nomor : /PKM-CBL/SOP/ /2016

Terbit ke :
DAFTAR
No.Revisi :
TILIK
Tg.!iber"k# :
$""m"% :

M. (MSOR
&PT P#skesm"s Cib"i#%g tt'

&%it : Pet#g"s Pe%'"+t"r"%

N"m" Pet#g"s :..
:..
T"%gg"
T"%gg" Pe"k"%""% :.
:.

Ti'"k
No Kegi"t"% 9" Ti'"k
Ber"k#
Apakah ?
1 Pet#g"
Pet#g"s%
s% me%,i")
me%,i")k"%
k"% +orm#
+orm#ir
ir '"% *"t"t"
*"t"t"%
% sert"
sert" %omor
%omor rek"m
rek"m
me'is ,"%g 'i)er#k"% #%t#k )e","%"%. 3orm#ir '"% *"t"t"% 
2 Pet#g"s Me%"%,"k"% ke)"'" )"sie% ,"%g '"t"%g ")"k" s#'"
)er%" berob"t Bi" be#m ber"rti )"sie% b"r# '"% bi" s#'"
ber"rti )"sie% "m" 
3 Pe","%"% ke)"'" )"sie% b"r# mei)#ti :

4 Pet#g"s Me%"%,"k"% i'e%tit"s )"sie% se*"r" e%gk") #%t#k 'i*"t"t

)"'" +orm#ir rek"m me'is )"sie% r""t ""% KB '"% K&P 

5 Me%,er"k"% KB ke)"'" )"sie% 'e%g"% )es"% #%t#k memb""

kemb"i bi" '"t"%g berob"t berik#t%," 

6 Me%,im)"% K&P ses#"i #r#t"% %omorek

7 Me%"%,"k"% ke#"% #t"m"%," g#%" mem#'"k"% m"%g"r"k"%

)"sie% ke )oiki%ik ,"%g ses#"i

8 Pe","%"% ke)"'" )"sie% "m" mei)#ti :

9 Sete" "kir )e","%"% kegi"t"%%," ,"it# :

10 Me%
Me%*"t
*"t"t
"t i'e%ti
i'e%tit"s
t"s )"'" b#k# regist
register
er )e%'"+t
)e%'"+t"r"
"r"%
% )"sie%
)"sie% r""t
r""t
""%.
11 Pet#g"s 3"rm"si me"k#k"% )e","%"% ke)"'" )"sie% 'i

)#skesm"s 
12 Me%
Me%*o*o
*o*okk"
kk"%
% #m"
#m" )"sie%
)"sie% 'e%g"%
'e%g"% #m"
#m" )e%'"+t
)e%'"+t"r"
"r"%
% )"sie%
)"sie%
r""t ""% 'e%g"% k"sir r""t ""% 
113 Pe%gg#%""% %omor rek"m me'is "g"r ti'"k ter"'i '#)ik"si 
14 Pe%gg#%""% +orm#ir rek"m me'is #%t#k )e%ge%'"i"% )e%gg#%""%
+orm#ir rek"m me'is.

15 Merek")iti"si #m" k#%#%g"% )"sie% b"r# '"% "m" #%t#k

ke)er#"% st"tisti* )#skesm"s 

COMPL(NC8 ;&ML($
COMPL(N C8 R(T8
R(T8 4CR5

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