1.
Medical Record
Dewi Windaningrum
Presented by
Jessica Arisa Diestananda

2.
What is medical record?
Medical record is both written
or recorded information about
identity, anamnesis, laboratory
report, diagnosis, and all
services and medical treatments
given to the inpatient,
outpatient or emergency patient
.(Dirjen Pelayanan Medis, 2006)

3.
What is medical record?
Medical record is a document
which contain patient
identification data, examination
record, treatment, medical
procedures and other services
that have been given to the
patient. (PMK 24 Tahun 2022)

4.
nction of medical record
Medical records can be used as legal evidence to protect patients,
providers (doctors, nurses and staff) or other health services as well
as managers and owners of health facilities against law.
A medical record file has administrative value, because its contents
involve actions based on authority and responsibility as medical and
paramedic personnel in achieving health service goals.
A medical record file has financial value because its contents can be used
as material for determining the cost of paying for services at health care
facilities. Without evidence of action/service records, payments cannot be
accounted for.
Suatu berkas rekam medis mempunyai nilai penelitian, karena isinya
mengandung data/informasi yang dapat digunakan sebagai aspek
penelitian dan pengembangan ilmu pengetahuan di bidang kesehatan
A medical record file has educational value, because its contents involve
data/information about the chronological development of medical record
services and activities provided to patients. This information can be used as
teaching material.
A medical record file has documentation value, because its contents
become a source of memory that must be documented and used as material
for accountability and hospital reports.

5.
Philosophy of Medical Record
The data in the medical record must be correct and
not manipulated.
The data in the medical record can be a source of
information for those who need it.
The data in the medical record must be accountable
for its validity.

6.
Definition of Medical Record File
A medical record file includes identification
information, patient’s medical history, medication
history, treatment history and medical directives.
A medical record file includes a variety of types of
"notes" entered over time by doctors, dentist,
healthcare professionals, therapist, nutritionist etc.
A medical record file is kept in the medical record room
by medical record staff who has been sworn to secrecy.
PMK No 269 Tahun 2008

7.
Content of Medical Record File
Medical record need to at least contain of:
 Patient’s identity
 Results of Physical and supporting examinations
 Diagnosis, treatments and follow-up plan of health
services
 Name and signature of the health care professionals
PMK No 24 Tahun 2022

8.
Content of Medical Record File
Electronic medical record contains of:
 Administrative documentation
At least it has to have registration documentation
 Clinical documentation
Contains all documentation of health services given
to the patients when they visited health facility
PMK No 24 Tahun 2022

9.
Medical Record Flow
Patient come to the
health care facility
Patient doing
registration at the
registration counter
Medical record staff
takes medical
record from medical
record room for old
patients
Patient wait to be
called at the
designated area
Medical record is
sent to designated
outpatient ward by
medical record staff
Patient’s receive
health care services
after the health care
professional receive
patient’s medical
record
Patient’s diagnosis
is written by health
care professional
Patient goes home
Medical record goes
back to medical
record room
Medical record staff
does: assembling,
coding, indexing
Medical record staff
does daily report
Medical record staff
does filing which
means storing the
medical record
Medical record staff
gives new medical
record number for
new patients

10.
Questions?
Which Permenkes use in the
presentation for the definition of medical
record?
a. PMK 21 Th 2022
b. PMK 22 Th 2022
What is the philsophy of medical
record?
a. Inquisitive
b. Informative
c. PMK 23 Th 2022
d. PMK 24 Th 2022
c. Insensitive
d. Imperative

11.
Questions?
What does F stand for in ALFRED?
a. Function
b. Feasibility
What does L stand for in ALFRED?
a. Liability
b. Legal
c. Farce
d. Financial
c. Liason
d. Language

12.
Questions?
In the medical record flow chart, what does
medical record staff do if the patient is new?
a. Give new medical record number
b. Give new medical record point
c. Give new medical record rate
d. Give new medical record amount
Which one of the following is NOT medical record
staff’s job?
a. Coding
b. Filing
c. Indexing
d. Shipping

13.
CREDITS: This
presentation template
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and includes icons by
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& images by Freepik
Thank you!