Peraturan Rekam Medis dari Kementrian Kesehatan

 Peraturan Rekam Medis dari Kementrian Kesehatan



Pada tahun 2008, Menteri Kesehatan Indonesia mengeluarkan peraturan baru mengenai rekam medis di Indonesia. Peraturan ini memiliki sembilan bab dengan 20 pasal di dalamnya. Peraturan baru ini memberikan perubahan tertentu yang telah disesuaikan dengan kebutuhan dan perkembangan di dunia kesehatan saat ini. Mengingat pentingnya sebuah rekam medis bagi berbagai pihak, baik dari pihak pasien hingga pihak pemerintahan, aturan ini sangat berguna untuk keberlangsungan iklim administrasi di dunia kesehatan yang baik.

Artikel kali ini menyajikan rangkuman tentang isi-isi yang terkandung dalam Permenkes Rekam Medis yang dikeluarkan pada tahun 2008 ini. Berikut adalah beberapa peraturan yang tertuang pada Peraturan Menteri Kesehatan Nomor 269/Menkes/Per/III/2008:

Bab I: Ketentuan Umum
Bab I memiliki satu buah pasal, yaitu Pasal 1. Pasal 1 berisi tentang definisi rekam medis, para profesional di bidang kedokteran seperti seorang dokter, dokter spesialis, dokter gigi, dan dokter gigi spesialis, sarana pelayanan kesehatan, tenaga kesehatan, pasien, catatan, dokumen, dan organisasi profesi di bidang kedokteran.

Bab II: Jenis dan Isi Rekam Medis
Bab II berisi 3 buah pasal, yaitu Pasal 2, Pasal 3, dan Pasal 4 yang menjelaskan tentang jenis dan isi rekam medis. Lebih lanjut lagi, Bab II Pasal 2 dalam Permenkes ini berisi tentang cara pendokumentasian rekam medis dan penyelenggaraan rekam medis secara elektronik.

Kemudian, Pasal 3 memberikan beberapa ketentuan berbagai informasi mengenai isi rekam medis untuk pasien rawat jalan, pasien rawat inap dan perawatan satu hari, pasien gawat darurat, pasien dalam keadaan bencana, pelayanan dokter spesialis atau dokter gigi spesialis, dan pelayan yang diberikan dalam ambulans ataupun pengelolaan masal. Selanjutnya, Pasal 4 berisi ketentuan dalam ringkasan pulang dan juga isi ringkasan pulang.

Bab III: Tata Cara Penyelenggaraan
Bab III Permenkes Rekam Medis juga memiliki 3 buah pasal. Pasal 5 memberikan informasi tentang pembuatan rekam medis oleh dokter atau dokter gigi yang menjalankan praktik dan prosedur pembuatan, pencatatan, revisi, dan juga validasinya. Dilanjutkan dengan Pasal 6 yang menyebutkan tentang tanggung jawab dokter, dokter gigi, dan/atau tenaga kesehatan dalam membuat rekam medis. Terakhir, Pasal 7 yang berisi tentang fasilitas yang harus disiapkan saat menyelenggarakan rekam medis.

Bab IV: Penyimpanan, Pemusnahan, dan Kerahasiaan
Bab IV Permenkes Rekam Medis membahas seputar penyimpanan, pemusnahan, dan kerahasiaan dokumen-dokumen yang berkaitan dengan rekam medis. Bab IV memiliki Pasal 8 yang berisi tentang penyimpanan rekam medis pasien rawat inap, persetujuan tindakan medis, dan ringkasan pulang.

Selain itu, Pasal 9 yang menjelaskan tentang penyimpanan dan pemusnahan rekam medis sarana pelayanan kesehatan non rumah sakit. Diikuti dengan Pasal 10 tentang kerahasiaan informasi tentang pasien dan tata cara permintaan rekam medis untuk keperluan tertentu. Terakhir ada Pasal 11 yang berfokus pada isi rekam medis dan tata cara penjelasan rekam medis.

Bab V: Kepemilikan, Pemanfaatan, dan Tanggung Jawab
Ada tiga buah pasal dalam Bab V yang mengatur tentang kepemilikan, pemanfaatan, dan tanggung jawab dokumen-dokumen yang berkaitan dengan rekam medis. Peraturan ini tertuang dalam Pasal 12 yang menjelaskan tentang kepemilikan rekam medis dan ringkasannya. Dilanjutkan dengan Pasal 13 tentang pemanfaatan rekam medis dan kepentingannya. Tidak ketinggalan Pasal 14 yang berisi tentang tanggung jawab pimpinan sarana pelayanan kesehatan terhadap kondisi rekam medis.

Bab VI: Pengorganisasian
Bab VI memiliki fokus pada pengorganisasian rekam medis yang tertuang pada Pasal 15 dengan fokus pada ketentuan pengelolaan rekam medis.

Bab VII: Pembinaan dan Pengawasan
Pembinaan dan pengawasan Permenkes Rekam Medis ini diatur dalam Pasal 16, yang menyebutkan pihak-pihak yang terlibat dalam pembinaan dan pengawasan peraturan menteri kesehatan tentang rekam medis dan fungsinya. Lalu, Pasal 17 yang menjelaskan tentang ketentuan pihak-pihak yang terlibat dalam pembinaan dan pengawasan peraturan menteri kesehatan tentang rekam medis untuk mengambil tindakan administratif.

Bab VIII: Ketentuan Peralihan
Bab VIII hanya memiliki satu buah pasal, yaitu Pasal 18 yang berisi tentang penyesuaian ketentuan oleh dokter, dokter gigi, dan sarana pelayanan kesehatan.

Bab IX: Ketentuan Penutup
Bab terakhir ini memberitahukan bahwa dalam Pasal 19 telah dijelaskan bahwa Peraturan Menteri Kesehatan Nomor 749a/Menkes/Per/XII/1989 sudah tidak berlaku lagi dan telah ditetapkannya pemberlakuan Peraturan Menteri Kesehatan Nomor 269/Menkes/Per/III/2008 pada Pasal 20.

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