MEDICAL RECORD

medical record is a file that

contains records and documents
about the patient's identity,
examination, treatment, actions
and other services that have
been provided to patients
Inpatient medical records at the hospital must
keep at least 5 years from the date the
patient was treated or discharged

after the 5-year time limit has been exceeded

the medical record can be destroyed, except
for a summary of return and inform consent
of medical treatment

the summary of discharge and inform consent

of medical treatment must be kept for a
period of 10 years from the date the summary
was made
 based on location, medical
record storage systems can
be divided into two types

SENTRALISASI DESENTRALISASI
CENTRALIZATION

centralization is all
information about a
More clearly, all
patient stored in one
recording services
file, both outpatient,
provided to
inpatient and
patient are in:
emergency unit
• One file/folder
information
• One location
• And managed by
one work unit.
 ADVANTAGES DEFICIENCY

•Reduce duplication
•need time in the
•Less costs for
service of medical
maintenance & space
•Work efficiency of records
•need a large space,
the officer
•Easy to be served at tools and a lot of
energy
any time
DECENTRALIZATION

medical record storage is

kept separate between
inpatient and outpatient
medical records. can be with
one unit number or with a
different number
 ADVANTAGES DEFICIENCY

•time efficient,
quickly served •duplicate medical
patients record-making
•light workload of •information about
officers the history being
•supervision of separated
medical records is •hindering service
easier because the when needed by
environment is other units
narrower.