Monthly Archives: March 2012

Pendidikan rekam medis di Indonesia

Kapankah awal dari pendidikan RMIK di Indonesia??

Location ◦1989, Indonusa Esa Unggul (IEU) Blora St. Univ. at Blora street, Central Jakarta City ◦1992, IEU Univ. at Arjuna street, Western Jakarta City ◦2010,   new name : Esa Unggul Univ. at the same place

UEU University Total graduated
1989-2000 180
2001-2005 354
2006-2010 157
 2011-2011  63

selesai @ hak cipta Lily Widjaja,AMdPK,SKM,MM

 

Cikal bakal rekam medis

Cikal bakal Rekam Medis
Goresan, lukisan, ataupun lambang-lambang tulisan yang merupakan catatan yang menggambarkan tentang ilmu medis dan kesehatan belum dapat kita sebut sebagai catatan Rekam Medis seperti apa yang kita jumpai pada zaman modern ini. Namun demikian walaupun wujudnya masih sangat primitif, catatan yang pada saat penulisannya dulu mungkin hanya diperuntukkan bagi kepentingan pribadi si penulis ternyata menjadi suatu peninggalan penting yang mampu memberi informasi tak ternilai bagi kita tentang ilmu kedokteran beserta perkembangannya . Ini membuktikan bahwa suatu yang dicatat / direkam dan disimpan serta dipelihara dengan baik, dapat dijadikan sumber ilmu atau bahan yang berguna di kemudian hari. Nampak jelas bahwa sejak zaman dahulu “Records” khususnya Medical Records menduduki tempat yang penting di dalam ilmu kedokteran, di bidang pelayanan medis, sama pentingnya seperti obat di bidang pelayanan penyembuhan.

ZAMAN PRIMITIF PALEOLITHICUM
Ditemuinya lukisan berwarna-warni yang berkilauan pada dinding Goa Old Stone Age yang berasal dari zaman  25000 BC . Walaupun lukisan ini belum menggambarkan secara khas hal-hal yang berkaitan dengan penyakit dan pengobatan, namun dari cara-cara mereka memilih bagian tubuh hewan sebagai sasaran penusukan, sedikitnya telah menunjukkan bahwa sudah ada pemahaman tentang letak organ-organ vital di dalam tubuh.
Selain itu pada Goa Paleolithic sejenis di Spanyol ditemui lukisan bayangan hitam yang menggambarkan tindakan trephanasi dan amputasi tulang jari tangan.
Lukisan berupa goresan dan pahatan pada dinding batu karya manusia pada zaman 12000- 14000 BC menunjukkan bahwa pada masa itu manusia telah mengenal pengobatan dengan menggunakan produk alam seperti ramuan dedaunan, olesan tepung, bubur bedak serta diet makanan. Disamping itu telah dilakukan pengobatan dengan tindakan psikoterapi dan fisioterapi.

ZAMAN MESOPOTAMIA (  4000 BC)

“HAMMURABI CODE”. Ditemukan di Iran tahun 1901- 1902 oleh seorang arkeolog Peancis.Kode Hammurabi ditulis pada Batu Diorits setinggi 2 meter, dan berasal dari zaman 1800-1700BC. Kode tersebut mengandung 282 undang-undang yang terbagi dalam 10 kelompok. Diantaranya kelompok ke 7 nomor 215-240 mencantumkan undang-undang tentang profesi kedokteran. Ini adalah legislasi Pertama dari profesi medis yang kita kenal sampai saat ini.

ZAMAN CINA KUNO (2700 BC – 1644)
Pada zaman Cina Kuno ilmu kedokteran terutama ilmu pengobatan telah berkembang sejak tahun 2700 BC.
Tokoh yang terkenal adalah :
Kaisar Shen Nung (2737BC) yang sangat terkenal dengan Pentsao yakni ilmu pengobatan herbal yang terbesar.
Kaisar Huang Tie (2697 BC) terkenal dengan Neiching , yang mendapat julukan dengan Kanon Pengobatan. Karya tulis peninggalan Cina kuno ditulis di atas bambu dengan idiogram mirip heiroglyph.
Dinasti Sung tahun 1241: Hsi Yuan Lu mengembangkan ilmu kedokteran Forensik untuk keperluan pengadilan.
Kaisar Kian Lung (1644) :mewariskan ensiklopedia yang terdiri dari 40 jilid buku. Yang disebut dengan The Golden Mirror of Medicine. Isinya banyak mengenai metode pengobatan seperti massage, operasi manipulasi dan seni pengobatan akupunktur.

selesai @ hak cipta Lily Widjaja,AMdPK,SKM,MM

IFHIMA (dahulu IFHRO)

I.PENDAHULUAN

1.Dalam rangka meningkatkan pengetahuan praktisi Rekam Medis dan Kesehatan Indonesia tentang Organisasi Internasional Manajemen informasi Kesehatan, perlu di sampaikan beberapa informasi terkait dengan badan international yang membina seluruh organisasi Manajemen Informasi Kesehatan sedunia, termasuk Indonesia yang saat ini dihimpun dalam IFHIMA kawasan Asia mulai tahun 2011 sampai 2013 dengan ketuanya Mrs Yukiko dari Jepang. Sebaigai informasi sebelumnya Indonesia sebagai ketua IFHRO South East Asia yaitu Ibu DR Gemala Hatta PhD.dari tahun 2009 sampai 2011 hasil keputusan kongres IFHRO di Seoul Korea Selatan.

2.Informasi ini sangat penting diketahui oleh para praktisi Rekam Kesehatan Indonesia.
Jakarta,April 2011
Pembina PORMIKI

Lily Widjaja,AMdPK,SKM,MM

II.HASIL KONGRES IFHRO MILAN NOVEMBER 2010
1.Perubahan nama IFHRO(International Federation of Health Record Organization) menjadi IFHIMA (International Federation Health Information Magagement Associassion)
2.Kongres ini diikuti oleh Tim dari FORMIKI yaitu Ibu pembina yaitu DR Gemala Hatta dan Lily WIdjaja ,MM serta Ketua Umum DPP FORMIKI . DR Gemala Hatta melaporkan kegiatan IFHRO Sout East Asia, sedangkan Presentasi oleh Lily Widjaja,MM dan Elsye.Presentasi tersebut di muat dalamJurnal IFHIMA 2011.
3, kONGRES YANG AKAN DATANG DIADAKAN DI MONTREAL CANADA 2013

III.PENGURUS PORMIKI MENGIKUTI KONGRES IFHRO
1.Kongres IHFRO Melbourne 2000
2.Kongres IHFRO Seoul 2007
3.KOngres IHFRO Milan 2010

IV.INFORMASI TENTANG IFHIMA (DULU IFHRO)

1.What is a Health Information Manager (HIM)?
apa yang dimaksud dengan Manejer Informasi Kesehatan?

The scope of practice of HIMs is described by the HIMAA as:

· “Health information managers (HIMs) design and manage information systems in the healthcare system

· HIMs collect and generate records and reports about patients who are being treated by doctors and other clinicians

· HIMs use their clinical knowledge of disease and surgical procedures, technical knowledge of computer systems and databases and their management skills to set up and monitor these systems

· HIMs also play a key role in the security and legal use of people’s medical records and health information by establishing appropriate procedures and handling and protecting personal data.”

2.IFHIMA
The International Federation of Health Information Management (IFHIMA) formerly known as IFHRO supports national associations and health record professionals to implement and improve health records and the systems, which support them. IFHIMA was established in 1968 as a forum to bring together national organizations committed to improvement in the use of health records in their countries. The founding organizations recognized the need for an international organization to serve as a forum for the exchange of information relating to health records and information technology.

The purposes of IFHIMA are to:

■promote the development and use of health records/information management in all countries
■advance the development and use of international health records/information management standards
■provide for the exchange of information on health record s/information management education requirements and training programs
■provide opportunities for education and communication between persons working in the field of health records/information management in all countries
■promote the use of technology and the electronic health record

IFHIMA is a non-profit organization affiliated with the World Health Organization (WHO) as a non-governmental organization (NGO). The Federation sends representatives to WHO meetings and works closely with WHO on specific projects of particular concern or interest to WHO in the field of health records and information systems.

IFHIMA also has a partnership with the International Medical Informatics Association (IMIA), which provides opportunities for interested professionals to share information through newsletters and to participation in meetings dedicated to healthcare informatics. The partnership also provides an opportunity for IFHIMA and IMIA to work together to promote health informatics and health records throughout the world.

IFHIMA activities include:

■International Health Records Congress: Every three years the Congress is hosted by one of the national member organizations. This is an opportunity to bring together member countries, other interested countries and individuals in an international forum to participate in educational sessions and networking opportunities.
■Newsletter: The International Health Records Newsletter, “The Link” is published at least annually on the website and provides information about health records activities in member countries as well as interesting and informative articles on the latest health information standards and technology.
■Educational programs: Educational programs and consultations may be provided to countries as and when required. Health records educational tools are also available for the training of health records professionals in the diverse area of health information management.
■International Committees, Task Groups and Projects: Members have the opportunity to serve on international committees, task groups or projects, which focus on health information management and health records.

IFHIMA Leadership:
The leadership of IFHIMA is comprised of the Executive Committee, which is made up of elected officials, the President, the President-Elect, and six Regional Directors representing the Europe, Americas, South East Asia, Western Pacific, Eastern Mediterranean, and Africa.

The Executive Committee reports to the General Assembly, which is made up of representatives from the National member associations. The General Assembly meets every three years at the time of the international Congress.

3.IFHIMA MEMBERSHIP
IFHIMA Membership

Membership in IFHIMA consists of:

■National membership is for health records/information management associations representing this field within each country. National members have full voting rights, can serve on the Executive Committee, and are represented at the General Assembly by a Director and Alternate Director.
■Associate membership is for individuals working in the field of health records/information management and those wishing to support the work of IFHIMA. Associate members can serve on committees, task groups, special projects, and attend the General Assembly, but do not hold office or vote.
■Corporate membership for reserved for companies providing healthcare services or interested in supporting the work of IFHIMA. Corporate members can serve on committees, task groups, special projects, and attend the General Assembly, but do not hold office or vote.
■Honorary membership is bestowed, by the Executive Committee, upon individuals who have earned exceptional merit in furthering the goals and interests of IFHIMA.
Benefits to membership in IFHIMA combine international networking opportunities, health records/information management educational programs and learning modules, certification of coders, practice tools and best practice, and much more.

4.IFHRO STRATEGIC FROM SEOUL CONGRESS 2008
IFHIMA’s Strategic Initiatives 2004 – 2010

1. Moving Forward 2007 – 2010

1.1 The 15th General Assembly, 27th May 2007, Seoul, Korea

The IFHIMA Executive Committee 2004-2007 continued to regularly monitor progress against the five strategic initiatives derived from the statements of need discussed at the 14th General Assembly in Washington DC in 2004: The issues surrounding confidentiality, privacy, security and personal health information had gathered pace globally and on 27th May 2007 the following resolution was put to the 15th IFHIMA General Assembly and was subsequently passed:

Resolution : Confidentiality/Security/Personal Health Information

Whereas, the principles of confidentiality, privacy, security and personal health information are global issues,
Be it resolved that:
The 15th General Assembly of the International Federation of Health Infomation Management Association (IFHIMA) is committed to the confidentiality, privacy and security of personal health information (PHI) And Encourages all countries to promulgate policies that support this resolution.

1.2 Executive Committee Meeting, 11th & 12th June 2008, Amsterdam

At the face-to-face meeting of the IFHIMA Executive Committee held in Amsterdam on 11th & 12th June 2008 the five key (strategic) initiatives identified in 2004 as shown above were reviewed and discussed in detail and it was subsequently agreed that ‘Privacy and Confidentiality’ was a concept within all of the IFHIMA strategic initiatives and not a stand alone item. Additionally ‘Clinical Data Management’’was a concept within Education and had been embedded in this initiative through the WHO-FIC-IFHIMA Joint Collaboration. It was therefore agreed that there would be three strategic initiatives for IFHIMA going forward (Electronic Health Record, Education, and The Needs of Developing Countries). It was appropriate to narrow the focus and scope into specific areas that would most benefit Health Information Management in the world. These three initiatives were then debated and preliminary actions for the following twelve months were agreed as follows:

1.2.1 Electronic Health Record

The IFHIMA EC agreed that they could provide up to date information as to the current state of the electronic record in their home countries/regions and individuals made a series of presentations on the topic at an International Session at an EHR conference hosted by the Dutch national association NVMA in Amsterdam in June 2008. All five of the presentations from Germany, Denmark, Canada, United States and the United Kingdom together with an additional paper “EHR in poor resource settings; the case of Kenya” were then posted on the IFHIMA web site for the information of IFHRO members and other visitors to the website.

Other member countries were then asked to contribute information as to the status of the record system in their respective countries including those where paper-based records need improvement as it was felt that this information would also be useful for the membership. Best practice systems can and should be documented for either electronic systems or paper record systems and IFHIMA member nations were invited to submit articles for the website detailing best practice systems and EHR status in their countries. It was agreed that a standardized form should be developed before the 16th General Assembly to be held in Milan and member countries will be asked to complete the form regarding national progress on the electronic record. A summary will then be compiled before the meeting and shared during the Assembly.

1.2.2 Education

This strategic initiative now has the subsets of Clinical Data Management and Privacy and Confidentiality. It was agreed that IFHIMA would continue the Joint Collaboration with WHO’s Family of International Classifications, which will start work on training and development of a certificate program for morbidity coders in 2009. An on-line ICD 10 training tool is being developed and it was agreed that links to the tool will be included on the IFHIMA website when it is completed.

It was also agreed that, subject to appropriate funding being received, a Community of Practice for Coders could hopefully be developed on the IFHIMA website.

IFHIMA will also provide input to the work on the development of an International HIM Curriculum by a Committee that AHIMA is coordinating and there will continue to be IFHIMA input to AHIMA’s annual Assembly on Education (AOE).

The IFHIMA Executive Committee agreed that one of IFHIMA’s goals for 2007-2010 would be to work towards the production of a global map of HIM education around the world and the development of a compendium of current information following the model agreed for EHR. National Directors would be engaged to provide an update on education in their countries including types of courses, levels, titles, credentials, distance education provision etc.

1.2.3 The Needs of Developing Countries

The IFHIMA Education Modules were reviewed by the Executive Committee and it was agreed that they were still current and relevant. These Modules will be supplemented in due course by documentation/guidelines under development by WHO-FIC-IFHIMA entitled “Documentation requirements to promote superior data capture” and two further documents on mortality and morbidity, which would have a focus on developing countries. On completion, the various documents will be posted on the IFHIMA web site as an additional resource for practitioners around the world.

A “Manual for Teachers” exists to accompany the Education Modules and it was agreed that this would be reviewed by the Executive Committee, updated where necessary and posted on the IFHIMA website as an adjunct to the Modules.

It was agreed that certification is important and how it is done is crucial to the advancement of the profession in countries such as Kenya. It was noted that distance learning and a generic curriculum will also be very important for such countries.

1.3 Executive Committee Meeting, 4th & 5th April 2009, Mannheim, Germany

At the face-to-face meeting of the IFHIMA Executive Committee held in Mannheim, Germany on 4th & 5th April 2009 the three strategic initiatives agreed upon in 2008 and outlined in section 2.2 above were reviewed and discussed in detail:

1.3.1 Electronic Health Record

Discussion took place about the development of another, new IFHIMA Education Module on the Electronic Health Record. This will be basic initially and will emphasise the importance of interoperability. The Regional IFHIMA Director for The Americas will undertake preliminary work on this module with the help of the Canadian Health Information Management Association (CHIMA).

1.3.2 Education

WHO-FIC-IFHIMA Joint Collaboration activities continue with major issues being the ICD-10 web based training tool, which is due for release during 2009. There is an urgent need to obtain funding to sustain the Certification process for mortality coders, to support the development of information sheets for key areas, continue the pilot project and to start work on possible testing methodologies for morbidity coders. There will be meetings of the Joint Collaboration in the fall of 2009 in Seoul, in spring of 2010 in Cologne, and in the fall of 2010 in Toronto.

IFHIMA is cooperating informally with the Royal College of Physicians, London to promulgate the College’s Standards for Record-Keeping and Guidelines for Clinicians. A link to the standards and the guidelines has been posted on the IFHIMA web site and there was a meeting with representatives of the Royal College on 29th April 2009 to explore further cooperation. An article about the standards and the development mechanisms was published in the June edition of IFHIMA Global News.

IHRIM, the UK national association has developed a new suite of examinations and qualifications specifically for overseas students at Foundation, Certificate and Diploma levels. (See 2.3.3 below “Needs of Developing Countries”).

1.3.3 The Needs of Developing Countries

The IFHIMA Education Modules were reviewed by the Executive Committee and it was agreed that they were still current and relevant and the “Manual for Teachers” will also be reviewed by the Executive Committee, updated where necessary and posted on the IFHIMA website as an adjunct to the Modules before the end of 2009.

It was agreed that certification for practitioners is important and how this is done is crucial to the advancement of the profession in countries such as Kenya. Robert Wamalwa, Regional IFHIMA Director for Africa is trying to initiate discussions with the WHO Regional Office regarding the provision of HIM education in Africa.

The Institute of Health Records & Information Management (IHRIM), which is the UK national association, asked Lorraine Nicholson, President of IFHIMA, to lead the development of a new suite of examinations and qualifications at Foundation, Certificate and Diploma levels specifically for overseas students, many of whom could be in developing countries. She was assisted by a reference group of Mauritian Health Record Practitioners all of whom were qualified by IHRIM having studied for and passed the examinations of the Institute at the different levels. It was agreed that the study materials for the new IHRIM Overseas Certificate would be based on the IFHIMA Education Modules, which are generic, and therefore not focused on healthcare practices and procedures specific to any one country, and they also reflect accepted professional best practice having been reviewed by an international panel prior to publication. The Education Modules are supplemented by IHRIM study materials on Medical Terminology, which will be available free of charge to Overseas Students during 2009/10. The IHRIM Education Strategy Panel, which met recently, reviewed and approved the overseas syllabus and the Panel believes that it will provide a more equitable and cost effective examination and qualification structure for overseas students, which will better meet their own professional needs and also the operational needs of their employing organisations. Students from anywhere around the world could take the IHRIM Overseas Certificate examination using the freely available IFHIMA Education Modules subject to registration by the required date and payment of the requisite examination fee. This would go some way towards addressing the issues relating to certification of practitioners discussed in 1.2.3 above.

4.IFHIMA Learning Center

The Learning Center provides educational materials and best practice guidelines for health records/health information management professionals around the world.

Education Modules for Basic Health Records Practice

■Index to Education Modules for Basic Health Records Practice
■Module 1: The Health Record
■Module 2: Patient Identification, Registration, and the Master Patient Index
■Module 3: Record Identification Systems, Filing, and Retention of Health Recrods
■Module 4: Healthcare Statistics
■Module 4: Exercises
■Module 4: Answer Key
■Module 5: Planning a Health Record Department
■Module 6: Administration and Management of the Health Record Department
■Manual for Educators

“Health information management professionals manage healthcare data and information resources. The profession encompasses services in planning, collecting, aggregating, analyzing, and disseminating individual patient and aggregate clinical data. It serves the healthcare industry including: patient care organizations, payers, research and policy agencies, and other healthcare-related industries.”

AHIMA 2000 Health Information Management: Professional Definition.

HIMs work in a wide variety of settings, including: hospitals and other health care facilities; federal and state health departments; research centres; health and disease registries; computing and software companies; and pharmaceutical companies and clinical trials centres.

Within these settings HIMs work in a wide variety of roles, including: Health Information Manager; Director of Information Services; Clinical Coder; Clinical Decision Support Officer; Privacy Manager; Freedom of Information Manager; Clinical Risk Manager; Quality Coordinator; Data Manager; Casemix Analyst; Business Manager; Project Manager; Clinical Trials Coordinator; and Health Registry Manager.

The Health Information Management Journal has published a series of career profiles which demonstrate the breadth of HIM skills and employment options.

6.The International Federation of Health Information Management (IFHIMA) formerly known as IFHRO supports national associations and health record professionals to implement and improve health records and the systems, which support them. IFHIMA was established in 1968 as a forum to bring together national organizations committed to improvement in the use of health records in their countries. The founding organizations recognized the need for an international organization to serve as a forum for the exchange of information relating to health records and information technology.

The purposes of IFHIMA are to:

■promote the development and use of health records/information management in all countries
■advance the development and use of international health records/information management standards
■provide for the exchange of information on health record s/information management education requirements and training programs
■provide opportunities for education and communication between persons working in the field of health records/information management in all countries
■promote the use of technology and the electronic health record

IFHIMA is a non-profit organization affiliated with the World Health Organization (WHO) as a non-governmental organization (NGO). The Federation sends representatives to WHO meetings and works closely with WHO on specific projects of particular concern or interest to WHO in the field of health records and information systems.

IFHIMA also has a partnership with the International Medical Informatics Association (IMIA), which provides opportunities for interested professionals to share information through newsletters and to participation in meetings dedicated to healthcare informatics. The partnership also provides an opportunity for IFHIMA and IMIA to work together to promote health informatics and health records throughout the world.

IFHIMA activities include:

■International Health Records Congress: Every three years the Congress is hosted by one of the national member organizations. This is an opportunity to bring together member countries, other interested countries and individuals in an international forum to participate in educational sessions and networking opportunities.
■Newsletter: The International Health Records Newsletter, “The Link” is published at least annually on the website and provides information about health records activities in member countries as well as interesting and informative articles on the latest health information standards and technology.
■Educational programs: Educational programs and consultations may be provided to countries as and when required. Health records educational tools are also available for the training of health records professionals in the diverse area of health information management.
■International Committees, Task Groups and Projects: Members have the opportunity to serve on international committees, task groups or projects, which focus on health information management and health records.

IFHIMA Leadership:
The leadership of IFHIMA is comprised of the Executive Committee, which is made up of elected officials, the President, the President-Elect, and six Regional Directors representing the Europe, Americas, South East Asia, Western Pacific, Eastern Mediterranean, and Africa.

The Executive Committee reports to the General Assembly, which is made up of representatives from the National member associations. The General Assembly meets every three years at the time of the international Congress.

6.CALENDER OF EVENT
CALENDAR OF EVENTS

2011 Spring National Convention of Korean Medical Record Association, April 15, 2011, Seoul, Korea

IFHIMA Executive Board meeting – June 2-3, 2011, Malaga, Spain

XII Congreso Nacional de Documentacion Medicia, June 2-4, 2011, Malaga, Spain Click here for information

AHIMA’s Assembly on Education and Faculty Development Institute, July 23-27, 2011, San Antonio, TX, Click here for information

37th Annual Meeting of Japan Society of Health Information Management, Fukuoka, Japan – September 29-30, 2011

2011 AHIMA Convention & Exhibits, October 1-6, 2011, Salt Lake City, Utah Click here for information

IFHIMA17th Congress and General Assembly, May 11-15, 2013, Montreal Canada

selesai @ hak cipta Lily Widjaja,AMdPK,SKM,MM

Hakekat rekam medis

Rekam Medis merupakan terjemahan dari Medical Record. Berbagai sebutan / istilah yang digunakan oleh banyak pihak , terutama dari unit pelayanan kesehatan baik rumah sakit, puskesmas maupun lainnya seringkali berbeda-beda. Penggunaan istilah “Rekam Medis” digunakan dalam Undang-undang Praktek Kedokteran, Permenkes 269 tahun 2008 tentang Rekam medis. Untuk itu kiranya perlu dimengerti apa yang dimaksud dengan Rekam Medis dan istilah lainnya yang digunakan. Selanjutnya perlu diluruskan istilah apa yang sebenarnya yang tepat untuk digunakan.

1. Rekam Medis: fakta yang berkaitan dengan keadaan pasien, riwayat penyakit dan pengobatan masa lalu serta saat ini yang ditulis oleh profesi kesehatan yang memberikan pelayanan pada pasien tersebut. (Health Information Management, Edna K.Huffman, 1999)
2. Rekam Kesehatan ialah kumpulan data keadan kesehatan individu yang mendapat pelayanan kesehatan yang meliputi data sosial pasien, catatan imunisasi, hasil pemeriksaan fisik sesuai dengan seluruh penyakit & pengobatan yang diperoleh selama mendapat pelayanan kesehatan. (Health Information Management, Edna K.Huffman, 1999)
3. Rekam medis elektronik/rekam kesehatan elektronik adalah kegiatan mengkomputerisasikan isi rekam kesehatan dan proses yang berhubungan dengannya. (Standar Profesi PORMIKI, 2007)
4. Pelayanan informasi kesehatan / Rekam Medis adalah kegiatan pelayanan penunjang secara profesional yang berorientasi pada kebutuhan informasi kesehatan bagi pemberi layanan kesehatan, administrator dan manajemen pada sarana pelayanan kesehatan serta instansi lain yang berkepentingan berdasarkan ilmu pengetahuan teknologi rekam medis (sintesa ilmu sosial, epidemiologi, terminologi medis, biostatistik, prinsip hukum medis dan teknologi informasi). (Standar Profesi PORMIKI, 2007)
5. Pelayanan informasi kesehatan adalah kegiatan pelayanan penunjang secara profesional yang berorientasi pada kebutuhan informasi kesehatan bagi pemberi layanan kesehatan, administrator dan manajemen pada sarana pelayanan kesehatan serta instansi lain yang berkepentingan berdasarkan ilmu pengetahuan teknologi rekam medis Pelayanan Rekam Medis/ Manajemen informasi kesehatan adalah kegiatan pelayanan penunjang yang berorientasi pada kepuasan pelanggan (SK MenPan no. 135/Kep/M.Pan /12/2002 tentang Jabatan Fungsional Perekam Medis dan Angka Kreditnya).
6. Administrator Informasi Kesehatan (Perekam Medis) merupakan profesi yang memfokuskan kegiatannya pada data pelayanan kesehatan dan pengelolaan sumber informasi pelayanan kesehatan dengan menjabarkan sifat alami data, struktur dan menterjemahkannya ke berbagai bentuk informasi demi kemajuan kesehatan dan pelayanan kesehatan perorangan, pasien dan masyarakat (Kongres V PORMIKI, tahun 2006).
7. Dokumen Elektronik (UU ITE/2008) adalah setiap Informasi Elektronik yang dibuat, diteruskan, dikirimkan, diterima, atau disimpan dalam bentuk analog, digital, elektromagnetik, optikal, atau sejenisnya, yang dapat dilihat, ditampilkan, dan/atau didengar melalui Komputer atau Sistem Elektronik, termasuk tetapi tidak terbatas pada tulisan, suara, gambar, peta, rancangan, foto atau sejenisnya, huruf, tanda, angka, Kode Akses,simbol atau perforasi yang memiliki makna atau arti atau dapat dipahami oleh orang yang mampu memahaminya
8. Computer-Based Patient Record (CPR): Rekam Medis pasien secara elektronik yang terdapat dalam suatu sistem yang didisain secara spesifik untuk membantu pemakai dengan dapat mengakses data secara lengkap dan akurat, mengingatkan, mendukung keputusan secara klinis, berkaitan dengan pengetahuan medis, dan alat bantu lain.
9. Electronic Medical Record (EMR) lebih luas lagi dengan system berbasis pada document imaging atau system yang telah diimplementasikan di ruang dokter
10. Electronic Health Record (EHR) istilah yang dipakai oleh IOM (Institute of Medicine) dan US Departement of Health and Human Services (HHS) sejak Juli 2003

selesai @ hak cipta Lily Widjaja,AMdPK,SKM,MM