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RSPAD GATOT SOEBROTO DITKESAD

DEPARTEMEN OBSTETRI DAN GINEKOLOGI

CATATAN MEDIK BERORIENTASI MASALAH

STATUS PASIEN OBSTETRI GINEKOLOGI

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(nama pasien dan suami)

RAHASIA

TAHUN : 2008 / 2009 / 2010 / 2011 / 2012 / 2013 / 2014 / 2015 ..................

HARAP DIBAWA SETIAP KALI PERIKSA

......... NO KLASIFIKASI MASALAH TANGGAL TANGGAL RINGKASAN (DIAGNOSIS KASUS) MULAI MASALAH PENATALAKSANAAN TERJADI SELESAI NAMA PPDS & DPJP CMBM – JJE 20081225 2 .RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl........ Nomor CM : ........................................................ Abdurachman Salen no 24 Jakarta 10410 DAFTAR MASALAH TETAP Nama Pasien : ............................

....... Pekerjaan :....... Keluhan Tambahan ………………………………………………………………………………………………………………… Riwayat Penyakit Sekarang ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Perangai Pasien ………………………………………………………………………………………………………………… Riwayat Haid ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Riwayat KB ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Riwayat Pernikahan ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… CMBM – JJE 20081225 3 ......... Nama :............. Agama :…………………………............................... ..................................................... Gol............ CM :................................................. Pendidikan :............ ....................... Abdurachman Salen no 24 Jakarta 10410 STATUS REKAM MEDIK (CMBM) PASIEN OBSTETRI GINEKOLOGI IDENTITAS PASIEN No........................................... ............ Suku :……………………………. Jam : .......................................... Agama :…………………………………..................RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl....... …… Gol.............................................. Pangkat :............. Pendidikan :.. Darah :…………………………..................... HP : …………………………………………… DATA DASAR Keluhan Utama ... ............... Diisi oleh : .... Pekerjaan :............. ................ Umur :............. ISTRI : SUAMI : Nama :.......................................................... Tanggal : ........... Alamat Rumah : …………………………………………………………………………………………… Nomor Telepon : ……………………………… No......................................................................... Pangkat :...................................................................................................... Umur :... Darah :………………………………….. Suku :…………………………............................

.................. ............................................................................................ ………………………………………………………………………………………….................................................................... CMBM – JJE 20081225 4 ............................. .............x/menit........... Tinggi Badan : ..................teratur/tidak ................................ 2.............................x/menit.......... …………………………………………………………………………………………..................................... 6........................ PEMERIKSAAN FISIK Diperiksa oleh : ……………………………................................................................................................................................................................................ mmHg Nadi : ....................................................................................................................................................................................................................... Status Generalis Keadaan Umum : ..........................................................RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl....................................... …………………………………………………………………………………………............................................................................................. C Pernafasan : .......... 3......................................................................................................................... teratur/tidak teratur o Suhu Tubuh : ................................................................................................................................................................ Kesadaran : ...................................................................................... ………………………………………………………………………………………….................................. .................................................................. ………………………………………………………………………………………….................. Tanggal :................................................................................................................. ........................... Jam :................ ............. Riwayat Penyakit Dahulu ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Riwayat Penyakit Keluarga ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ……………………………………… Catatan Penting Selama Asuhan Antenatal ................................................................. ......... ....................................................................................... .................................................................................. 5..................................... kg Tekanan Darah : ........................ 4................................... …………………………………………………………………………………………........................ Abdurachman Salen no 24 Jakarta 10410 Riwayat Obstetri 1....................................……cm Berat Badan : ………….................................

................................................................................................... ..................................................... Abdurachman Salen no 24 Jakarta 10410 Status Obstetri / Ginekologi 1............................................. 2..................... Inspekulo : .................................. ................................... ........................................... ............. ...................................................................................................................................................................................................................................................................................................................................... ............................................................................................................................................................................................ ..................................................................................................................................................................................................................................................................................................................................... .. ...... ............................................................................................................................................................................................................................................................................................ 3.......................................................................................................... ....................................................................................................................................................................................................................................... .............. ... .................................... ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ............................................................................................................. ........................................................................................................................................................... ..................................................................... CMBM – JJE 20081225 5 ..... Periksa Dalam : ...................................................................................................................................................................................................................................................................... ......RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl.................................................................................................................................. ................................................................. Periksa Luar : ................................................................................................................................................................................ .................................................... ............................................................................................................................................ .................................................................................................................. ............................................................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................................................................................................... ......................................................... Pelvimetri Klinik ( khusus ibu hamil / melahirkan ): ......................................................................................................................................................................................................................................................................................................................................................................................................................................... ...... .........................................

............................................................................................................................................................................. ............................................................................................................................................. ........................................... CMBM – JJE 20081225 6 ..................................... .................................................................. .... PROGNOSIS IBU : ......................................................................................................................................................................................... JANIN : ..................................................................................................................... ............................................................... DIAGNOSIS KERJA IBU : ...................................................................................................... ............................................................................................................................................................................................................................................... ........................................................................................................................................................................................ ........................................................... .......................................................................................................... ......................................................................... Abdurachman Salen no 24 Jakarta 10410 PEMERIKSAAN PENUNJANG DIAGNOSTIK (berisi data pemeriksaan penunjang diagnostik yang sudah dimiliki pasien sebelum pemeriksaan saat ini dilakukan) ..................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. . ....................................................................................................................................... ..................................................................................................................................... JANIN : ............................................................................................................................................................................................................. ............................... ................RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl................................................................................................................................................................................................................................................................................................. ...................................................................................................................................................................................................................................... ................................................................................................................................

............................................ ................................................................................... Abdurachman Salen no 24 Jakarta 10410 PENATALAKSANAAN AWAL Rencana Diagnostik : ................................................................................................................................................................................................................................................................................................................................ ..................................................................................................................................................................................................................................................................................................................................................................................................... ........................................... ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ............................................. ............... ………………………………………………………………………………………………………………… Rencana Pendidikan : ............................................... ............... Rencana Terapi : ………………………………………………………………………………………………………………… ............................................................................................................................…………………………………………………………………………………………………………… .................................... ................................................................................................................................................................................................................................................................................................................................................... ........................... ...................................................................................................................................................................................... ......... ................................................................................................................................................. Tanda tangan : ........................... ..... ............................................................................................................................................................................................................................................................................................................................. CMBM – JJE 20081225 7 .................................................................................. Tanda tangan : ............................ .................................................................................................................………………………........................................................................................................................................................................................ PPDS : ............. .............................................................. ..............................RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl.............................................................................................................. ............................................. DPJP : ............................ ..................... ................................................................................................................................................................................................................................ ................................................

JAM. Abdurachman Salen no 24 Jakarta 10410 DATA PENTING LAINNYA Nama Pasien : …………………………………..RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl.. TGL. CMBM – JJE 20081225 8 . …… Nomor CM : ……………………………. DATA PENTING LAIN YANG TERKAIT DENGAN TANDA PEMERIKSA PENATALAKSANAAN PASIEN TANGAN Data yang ditulis mencakup hal penting yang dapat mempengaruhi penatalaksanaan pasien.

............. Abdurachman Salen no 24 Jakarta 10410 PENATALAKSANAAN LANJUTAN ( S.. JAM..O..... dimengerti......A.............P. TEMUAN KLINIS DAN PENATALAKSANAAN TANDA PEMERIKSA (ditulis runut sesuai SOAP..................... Nomor CM : .......) Nama Pasien : ...... TGL.......RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl.......... tidak dicoret/dihapus) TANGAN CMBM – JJE 20081225 9 .................

... Nomor CM : ......... tidak dicoret/dihapus) TANGAN CMBM – JJE 20081225 10 ........ TEMUAN KLINIS DAN PENATALAKSANAAN TANDA PEMERIKSA (ditulis runut sesuai SOAP........ dimengerti...P............RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl... TGL................... JAM........ Abdurachman Salen no 24 Jakarta 10410 PENATALAKSANAAN LANJUTAN ( S...) Nama Pasien : .......O....................A.......

..A..... Nomor CM : ............ JAM.......O.. Abdurachman Salen no 24 Jakarta 10410 PENATALAKSANAAN LANJUTAN ( S..) Nama Pasien : .. TEMUAN KLINIS DAN PENATALAKSANAAN TANDA PEMERIKSA (ditulis runut sesuai SOAP........................... TGL........P.............RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl.................. tidak dicoret/dihapus) TANGAN CMBM – JJE 20081225 11 ..... dimengerti.......

.......... Nomor CM : ....... JAM.......... dimengerti..RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl....) Nama Pasien : .......A............................... Abdurachman Salen no 24 Jakarta 10410 PENATALAKSANAAN LANJUTAN ( S............ TGL....P.. tidak dicoret/dihapus) TANGAN CMBM – JJE 20081225 12 ....O............. TEMUAN KLINIS DAN PENATALAKSANAAN TANDA PEMERIKSA (ditulis runut sesuai SOAP....

..... dimengerti....P...... tidak dicoret/dihapus) TANGAN CMBM – JJE 20081225 13 .. Nomor CM : ..............O.......... Abdurachman Salen no 24 Jakarta 10410 PENATALAKSANAAN LANJUTAN ( S... JAM................. TGL....) Nama Pasien : ................ TEMUAN KLINIS DAN PENATALAKSANAAN TANDA PEMERIKSA (ditulis runut sesuai SOAP.........A...............RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl.....

..... tidak dicoret/dihapus) TANGAN SOAP ini dilanjutkan pada lembar pengamatan lanjut TAMBAHAN CMBM – JJE 20081225 14 ............... TGL..... TEMUAN KLINIS DAN PENATALAKSANAAN TANDA PEMERIKSA (ditulis runut sesuai SOAP.... Abdurachman Salen no 24 Jakarta 10410 PENATALAKSANAAN LANJUTAN ( S............................................) Nama Pasien : .RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl......A.....O. JAM....... dimengerti.P......... Nomor CM : .......

......................RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl...... ............. CTG....... TGL.................. HASIL PEMERIKSAAN PENUNJANG TANDA PEMERIKSA (tulis secara ringkas hasil pemeriksaan USG......... Nomor CM : .......... JAM. Abdurachman Salen no 24 Jakarta 10410 RINGKASAN HASIL PEMERIKSAAN PENUNJANG Nama Pasien : .... dll) TANGAN CMBM – JJE 20081225 15 .................

......RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl.... TGL. Abdurachman Salen no 24 Jakarta 10410 RINGKASAN HASIL KONSULTASI ANTAR DEPARTEMEN / DIVISI Nama Pasien : ………………………………………… Nomor CM : ……………………. HASIL KONSULTASI TANDA PEMERIKSA (tulis secara ringkas... JAM... dimengerti dan runut) TANGAN CMBM – JJE 20081225 16 .

...............RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl...... Nomor CM : .... mencakup hal penting) TANGAN CMBM – JJE 20081225 17 ........ PERSETUJUAN TINDAK MEDIK TANDA PEMERIKSA (tulis secara ringkas.. dimengerti.. Abdurachman Salen no 24 Jakarta 10410 RINGKASAN PERSETUJUAN TINDAK MEDIK Nama Pasien : ……………………………………... JAM. TGL..............

URAIAN ISI RESEP DOKTER TANDA PEMERIKSA (mencakup nama.. Nomor CM : ……………………………… TGL. Abdurachman Salen no 24 Jakarta 10410 SALINAN (COPY) RESEP DOKTER Nama Pasien : ………………………………………. cara dan catatan penting obat) TANGAN CMBM – JJE 20081225 18 .RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. JAM. dosis.