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Morbili Rumah Sakit Mulia Amuntai TAHUN 2019: Clinical Pathways

This clinical pathway document contains information about a patient's hospital visit, including their diagnosis of morbili, treatment received over 5 days consisting of medications like paracetamol and vitamin A, examinations and tests performed, and outcomes. The document tracks the patient's symptoms, condition, and care on a daily basis. It concludes with the final diagnosis, codes for billing, treatments provided, and signatures of the treating nurse, doctor and verifier.

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Nida Ulpah
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143 views2 pages

Morbili Rumah Sakit Mulia Amuntai TAHUN 2019: Clinical Pathways

This clinical pathway document contains information about a patient's hospital visit, including their diagnosis of morbili, treatment received over 5 days consisting of medications like paracetamol and vitamin A, examinations and tests performed, and outcomes. The document tracks the patient's symptoms, condition, and care on a daily basis. It concludes with the final diagnosis, codes for billing, treatments provided, and signatures of the treating nurse, doctor and verifier.

Uploaded by

Nida Ulpah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CLINICAL PATHWAYS

MORBILI
RUMAH SAKIT MULIA AMUNTAI
TAHUN 2019
Nama Pasien: Umur: Berat Badan: Tinggi Badan: Nomor Rekam Medis:
…………………………………………………… ……………… ……………..kg …………..cm …………………………….
Diagnosis Awal: ………………………………. Kode ICD 10 : …………………… Rencana rawat : 5 hari
R. Rawat Tgl/Jam msk: Tgl/Jam klr: Lama Rwt Kelas: Tarif/hr (Rp): Biaya (Rp):
Aktivitas Pelayanan ……………. ……………… ……………… ……... hari …….. …………. …………..
Hari Rawat 1 Hari Rawat 2 Hari Rawat 3 Hari Rawat 4 Hari Rawat 5
Hari Sakit: … Hari Sakit: … Hari Sakit: … Hari Sakit: … Hari Sakit: …
Diagnosis:
ƒ Penyakit Utama ……………… ……………… ……………… ……………… ………………
ƒ Penyakit Penyerta ……………… ……………… ……………… ……………… ………………
ƒ Komplikasi ……………… ……………… ……………… ……………… ………………
Asessmen Klinis:
ƒ Pemeriksaan dokter ……………… ……………… ……………… ……………… ……………… ………………
ƒ Konsultasi ……………… ……………… ……………… ……………… ……………… ……………..
Pemeriksaan Penunjang: DTL, U, F ……………… ……………… ……………… ……………… ……………..
Tindakan: ……………… ……………… ……………… ……………..
Obat obatan:
ƒ Parasetamol 3 x …mg ………………… ………………… ………………… ……………… ………………… ……………..
ƒ Vitamin A 100 000 IU ………………… ………………… ………………… ……………… …………………
ƒ Talk Salisilik ………………… ………………… ………………… ……………… …………………
Nutrisi: ……………… ……………… ……………… ……………… ……………… ……………..
Mobilisasi: ……………… ……………… ……………… ……………… ……………… ……………..
Hasil (Outcome):
ƒ Kesadaran ……………… ……………… ……………… ……………… ………………
ƒ Febris ……………… ……………… ……………… ……………… ………………
ƒ Sesak ……………… ……………… ……………… ……………… ………………
Pendidikan/R. Pemulangan: Penjelasan penyakit. Gizi dan Imunisasi Kontrol poliklinik
Varians: ……………… ……………… ……………… ……………… ………………

Jumlah Biaya
Nama Perawat: Diagnosis Akhir: ICD 10 Jenis Tindakan: ICD9–CM
……………………………. ƒ Utama Morbili B 05 ƒ Visite/Konsul: Anamnesis
Nama Dokter: ƒ Penyerta ………………………… ……….. ƒ Visite/Konsul Pemeriksaan Fisik
……………………………. ………………………… ……….. ƒ Pemeriksaan mikroskop darah
Nama Pelaksana ƒ Komplikasi ………………………… ……….. ƒ Pemeriksaan rutin urin dan feses
Verifikasi: ………………………… ……….. ƒ …………………………………… ……..
………………………….. ………………………… ……….. ƒ …………………………………… ……..

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