Lampiran Terminologi Resume Medis Rawat Jalan

Struktur Kamus KFA

Struktur Kamus KFA
Gambar 1. Struktur Kamus KFA
Tabel 1. Deskripsi Bahan Zat Aktif
DeskripsiBahan Zat Aktif

Tag (singkatan)

BZA

Format kode (numbering/ digit)

91xxxxxx

Tata cara penamaan

Nama Molekul Kimia

Contoh penulisan penamaan

Paracetamol

Atribut

  • Satuan ukur (UCUM)

  • Referensi Kode dari Sumber Lain
    mis. PubChem, CAS, ATC

Tabel 2. Deskripsi Bahan Zat Aktif
DeskripsiProduk Obat Virtual

Tag (singkatan)

POV

Format kode (numbering/ digit)

92xxxxxx

Tata cara penamaan

Zat Aktif + Kekuatan + Satuan + Bentuk Sediaan

Contoh penulisan penamaan

Paracetamol 500 mg Tablet

Atribut

  • Zat Aktif

  • Kekuatan

  • Satuan Kekuatan (UCUM)

  • Satuan Produk (unit terkecil)

  • Golongan Obat

  • Bentuk Sediaan

  • Kelas Terapi (5 Level ATC - WHO)

Tabel 3. Deskripsi Bahan Zat Aktif
DeskripsiProduk Obat Aktual

Tag (singkatan)

POA

Format kode (numbering/ digit)

93xxxxxx

Tata cara penamaan

Zat Aktif + Kekuatan + Satuan + Bentuk Sediaan + (Merek Dagang)

Contoh penulisan penamaan

Paracetamol 500 mg Tablet (Panadol)

Atribut

  • Semua atribut di POV

  • Nama Dagang

  • Eksipien

  • Formula Nasional

  • Program Kesehatan

  • Tayang LKPP

  • Produksi buatan (impor / lokal)

  • TKDN

  • Skor TKDN

  • Skor BMP

  • Referensi Kode dari Sumber lain
    mis. BPOM, LKPP

Pemetaan Perubahan Kode Resume Medis Rawat Jalan

Variabel Prognosis

Tabel 4. Prognosis
Value SetClinicalImpression.prognosisCodeableConcept[i].coding.systemClinicalImpression.prognosisCodeableConcept[i].coding.codeClinicalImpression.prognosisCodeableConcept[i].coding.displayVersi

1. Baik;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

PR000001

Prognosis baik

Versi 1.2

http://snomed.info/sct

170968001

Prognosis good

Versi 2.0

2. Dubia et bonam / cenderung baik;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

PR000002

Prognosis dubia et bonam / cenderung baik

Versi 1.2

http://snomed.info/sct

65872000

Fair prognosis

Versi 2.0

3. Dubia et malam / cenderung tidak baik;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

PR000003

Prognosis dubia et malam / cenderung tidak baik

Versi 1.2

http://snomed.info/sct

67334001

Guarded prognosis

Versi 2.0

4. Tidak baik

http://terminology.kemkes.go.id/CodeSystem/clinical-term

PR000004

Prognosis tidak baik

Versi 1.2

http://snomed.info/sct

170969009

Prognosis bad

Versi 2.0

Variabel Kondisi Saat Meninggalkan Rumah Sakit

Tabel 5. Kondisi Saat Meninggalkan Rumah Sakit
Value SetCondition.code.coding.systemCondition.code.coding.codeCondition.code.coding.displayVersi

1. Stabil;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

MN000001

Stabil

Versi 1.2

http://snomed.info/sct

359746009

Patient’s condition stable

Versi 2.0

2. Tidak stabil;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

MN000002

Tidak stabil

Versi 1.2

http://snomed.info/sct

162668006

Patient’s condition unstable

Versi 2.0

3. Perbaikan;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

MN000003

Perbaikan

Versi 1.2

http://snomed.info/sct

268910001

Patient’s condition improved

Versi 2.0

Variabel Tingkat kesadaran

Tabel 6. Tingkat kesadaran
Value SetObservation.code.coding.systemObservation.code.coding.codeObservation.code.coding.displayVersi

1. Sadar Baik/Alert : 0

http://terminology.kemkes.go.id/CodeSystem/clinical-term

TK000001

Alert

Versi 1.2

http://snomed.info/sct

248234008

Mentally alert

Versi 2.0

2. Berespon dengan kata-kata/Voice : 1

http://terminology.kemkes.go.id/CodeSystem/clinical-term

TK000002

Voice

Versi 1.2

http://snomed.info/sct

300202002

Response to voice

Versi 2.0

3. Hanya berespons jika dirangsang nyeri/pain : 2

http://terminology.kemkes.go.id/CodeSystem/clinical-term

TK000003

Pain

Versi 1.2

http://snomed.info/sct

450847001

Response to pain

Versi 2.0

4. Pasien tidak sadar/unresponsive : 3

http://terminology.kemkes.go.id/CodeSystem/clinical-term

TK000004

Unresponsive

Versi 1.2

http://snomed.info/sct

422768004

Unresponsive

Versi 2.0

5. Gelisah atau bingung : 4

http://terminology.kemkes.go.id/CodeSystem/clinical-term

TK000005

Gelisah

Versi 1.2

http://snomed.info/sct

130987000

Acute confusion

Versi 2.0

6. Acute Confusional States : 5

http://terminology.kemkes.go.id/CodeSystem/clinical-term

TK000006

Acute Confusional States

Versi 1.2

http://snomed.info/sct

2776000

Delirium

Versi 2.0

Variabel Rencana Tindak Lanjut / Cara Keluar dari Rumah Sakit

Tabel 7. Rencana Tindak Lanjut / Cara Keluar dari Rumah Sakit
Value SetServiceRequest.code.coding.systemServiceRequest.code.coding.codeServiceRequest.code.coding.displayVersi

4. Rawat inap;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

TL000001

Rawat inap

Versi 1.2

http://snomed.info/sct

737481003

Inpatient care management

Versi 2.0

Variabel Edukasi

Tabel 8. Edukasi
Value SetProcedure.code.coding.systemProcedure.code.coding.codeProcedure.code.coding.displayVersi

1. Proses penyakit, diagnosis, dan rencana asuhan;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

ED000001

Edukasi Proses penyakit, diagnosis, dan rencana asuhan;

Versi 1.2

http://snomed.info/sct

84635008

Disease process or condition education

Versi 2.0

2. Obat-obatan;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

ED000002

Edukasi obat-obatan

Versi 1.2

http://snomed.info/sct

967006

Medication education

Versi 2.0

3. Rehabilitasi medis;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

ED000003

Edukasi Rehabilitasi Medis

Versi 1.2

http://snomed.info/sct

410082002

Rehabilitation therapy education

Versi 2.0

4. Manajemen nyeri;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

ED000004

Edukasi Manajemen Nyeri

Versi 1.2

http://snomed.info/sct

712651001

Education about pain

Versi 2.0

5. Gizi;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

ED000005

Edukasi Gizi

Versi 1.2

http://snomed.info/sct

61310001

Nutrition education

Versi 2.0

6. Cuci tangan;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

ED000006

Edukasi Cuci Tangan

Versi 1.2

http://snomed.info/sct

698608004

Hand washing education

Versi 2.0

7. Penggunaan alat medis;

http://terminology.kemkes.go.id/CodeSystem/clinical-term

ED000007

Edukasi Penggunaan Alat Medis

Versi 1.2

http://snomed.info/sct

362978005

Medical equipment or device education (procedure)

Versi 2.0

Matriks Skenario Peresepan dan Pengeluaran Obat

Keterangan : +
* NC : Non-compound (non racikan)
* SD : Give of such doses (dtd)
* EP : Divide into equal part (tablet dipecah).
Tabel 9. Matriks Skenario Peresepan dan Pengeluaran Obat
Use CaseMedication.code MedicationRequestMedication.ingredient MedicationRequestMedicationRequestMedication.code MedicationDispenseMedication.ingredient MedicationDispenseMedicationDispense (Instruction)Valid/Invalid

Obat Pakem Tunggal (NC)

R/ Paracetamol 500 mg

93xxx

-

-

93xxx

-

Valid

92xxx

-

-

93xxx

-

Valid (Dengan ketentuan kode 93 untuk Medication.code MedicationDispense sebaiknya merupakan turunan dari kode 92 di Medication.code MedicationRequest)

91xxx

-

-

93xxx

-

Invalid

Racikan Non-dtd (EP)

  • R/ Paracetamol 500 mg 10 tab

  • Vitamin B6 10mg 10 tab

  • Dibuat 30 kapsul

-

Paracetamol:

  • Medication.ingredient.itemCodeableConcept → 93xxx

  • Medication.ingredient.strength.num : 10/tab

  • Medication.ingredient.strength.denominator : 30/kap

MedicationRequest.dispenseRequest.quantity → 30

-

  • Medication.ingredient.itemCodeableConcept → 93xxx

  • Medication.ingredient.strength.numerator : 10/tab

  • Medication.ingredient.strength.denominator : 30/kap

MedicationDispense.quantity → 30

Valid

-

Vitamin B6:\

  • Medication.ingredient.itemCodeableConcept→ 92xxx

  • Medication.ingredient.strength.numerator: 10/tab

  • Medication.ingredient.strength.denominator: 30/kap

MedicationRequest.dispenseRequest.quantity → 30

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 10/tab

  • Medication.ingredient.strength.denominator: 30/kap

MedicationDispense.quantity → 30

Valid

Racikan dtd (SD/ tidak ada sisa)

  • R/ Paracetamol 125 mg/ kapsul > perlu 5 tab (20 kapsul x 125 / 500mg)

  • Vitamin B6 20 mg/ kapsul > perlu 40 tab (20 kapsul x 20 / 10mg)

  • Dibuat 20 kapsul

-

Paracetamol:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 125/mg

  • Medication.ingredient.strength.denominator: 1/kap

MedicationRequest.dispenseRequest.quantity → 20

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 5/tab

  • Medication.ingredient.strength.denominator: 20/kap

MedicationDispense.quantity → 20

Valid

-

Vitamin B6:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 20/mg

  • Medication.ingredient.strength.denominator: 1/kap

MedicationRequest.dispenseRequest.quantity → 20

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 40/tab

  • Medication.ingredient.strength.denominator: 20/kap

MedicationDispense.quantity → 20

Valid

Racikan dtd (SD/ ada sisa)

Narkotika

  • R/ Morphine Hydrochloride 3 mg > perlu 7.5 tab (25 kapsul x 3 / 10mg)

  • Diazepam 1 mg Tablet > perlu 12,5 tab (25 kapsul x 1 / 2mg)

  • Dibuat 25 kapsul

-

Morphine Hydrochloride

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 3/mg

  • Medication.ingredient.strength.denominator: 1/tab

MedicationRequest.dispenseRequest.quantity → 25

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 7,5/tab

  • Medication.ingredient.strength.denominator: 25/kapsul

MedicationDispense.quantity → 25

Valid (Penulisan di Medication.ingredient.strength.numerator Medication Dispense sesuai yaitu 7.5tab, tidak dilakukan pembulatan)

-

Diazepam

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 3/mg

  • Medication.ingredient.strength.denominator: 1/tab

MedicationRequest.dispenseRequest.quantity → 25

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 12,5/tab

  • Medication.ingredient.strength.denominator: 25/kapsul

MedicationDispense.quantity → 25

Valid (Penulisan di Medication.ingredient.strength.numerator Medication Dispense sesuai yaitu 12.5tab, tidak dilakukan pembulatan)

Non-Narkotika

  • R/ Paracetamol 125 mg/ kapsul > perlu 7.5 tab (30 kapsul x 125 /500mg)

  • Vitamin B6 12,5 mg/ kapsul > perlu 37,5 tab (30 kapsul x 12,5 / 10mg)

  • Dibuat 30 kapsul

-

Paracetamol:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 125/mg

  • Medication.ingredient.strength.denominator: 1/tab

MedicationRequest.dispenseRequest.quantity → 30

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 8/tab

  • Medication.ingredient.strength.denominator: 30/kapsul

MedicationDispense.quantity → 30

Valid (Penulisan di Medication.ingredient.strength.numerator Medication Dispense adalah pembulatan ke atas yaitu dari 7.5 tab menjadi 8tab, tetapi yang digunakan tetap 7,5tab)

-

Vitamin B6:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 12.5/mg

  • Medication.ingredient.strength.denominator: 1/tab

MedicationRequest.dispenseRequest.quantity → 30

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 37.5/tab

  • Medication.ingredient.strength.denominator: 30/kap

MedicationDispense.quantity → 30

Valid (Penulisan di Medication.ingredient.strength.numerator Medication Dispense adalah pembulatan ke atas yaitu dari 37.5 tab menjadi 38tab, tetapi yang digunakan tetap 37,5tab)

Obat Minum (NC tidak sisa)

  • R/ Paracetamol 120 mg/5 mL Sirup

  • Paracetamol 5 ml diminum 4-6 jam sekali bila demam selama 24 hari

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

93xxx

Paracetamol Sirup

Medication.ingredient.itemCodeableConcept → 91xxx * Medication.ingredient.strength.numerator : 120 mg * Medication.ingredient.strength.denominator : 5mL

-

Valid

92xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

Valid

Obat Minum (NC sisa)

  • R/ Paracetamol 120 mg/5 mL Sirup

  • Paracetamol 5 ml diminum 4-6 jam sekali bila demam selama 30 hari

  • 1 botol 60 ml maka diperlukan 5mlx30 / 60ml = 2.5

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

Valid (Perlu catatan dari dokter obatnya harus dihabiskan atau tidak)

92xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

Valid

Obat Suntik (NC tidak sisa)

  • R/ Insulin Human Analog (Rapid Acting) 100 IU/mL Injeksi (NOVORAPID, 3 mL)

  • Suntik 3 kali sehari 10 Unit sebelum makan selama 30 hari - perlu 3 cartridge (100IU/ml x 3 mL / (3x10IU) = 10 hari 1 cartridge

  • 30 hari maka perlu 30/10 = 3 cartridge

93xxx

Insulin Human Analog:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 100[U]

  • Medication.ingredient.strength.denominator: 1/mL

-

93xxx

Insulin Human Analog :

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 3/cartridge

  • Medication.ingredient.strength.denominator: 9/mL

-

Valid

92xxx

Insulin Human Analog:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 100[U]

  • Medication.ingredient.strength.denominator: 1/mL

-

93xxx

Insulin Human Analog :

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 3/cartridge

  • Medication.ingredient.strength.denominator: 9/mL

-

Valid

Obat Suntik (NC sisa)

  • R/ Insulin Human Analog (Rapid Acting) 100 IU/mL Injeksi (NOVORAPID, 3 mL)

  • Suntik 3 kali sehari 8 Unit sebelum makan selama 30 hari - perlu 3 cartridge (100IU/ml x 3 mL / (3x8IU) = 12,5 hari 1 cartridge

  • 30 hari maka perlu 30/12.5= 2.4 cartridge

93xxx

Insulin Human Analog:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 100[U]

  • Medication.ingredient.strength.denominator: 1/mL

-

93xxx

Insulin Human Analog :

  • Medication.ingredient.itemCodeableConcept→ 91/xxx

  • Medication.ingredient.strength.numerator: 2.4 cartridge

  • Medication.ingredient.strength.denominator: 7.2/mL

-

Valid (Perlu catatan dari dokter obatnya harus dihabiskan atau tidak)

92xxx

Insulin Human Analog:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 100[U]

  • Medication.ingredient.strength.denominator: 1/mL

-

93xxx

Insulin Human Analog :

  • Medication.ingredient.itemCodeableConcept→ 91/xxx

  • Medication.ingredient.strength.numerator: 2.4 cartridge

  • Medication.ingredient.strength.denominator: 7.2/mL

-

Valid

Alur Pengiriman DICOM pada Fasilitas Pelayanan Kesehatan Yang Memiliki MWL

Alur Pengiriman DICOM
Gambar 2. Alur Pengiriman DICOM

Alur Pengiriman DICOM pada Fasilitas Pelayanan Kesehatan Yang Tidak Memiliki MWL

Alur Pengiriman DICOM
Gambar 3. Alur Pengiriman DICOM