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FORMAT

CLINICAL PATHWAYS
RAWAT INAP 5 HARI

RSUD PALEMBANG BARI


KOTAMADYA PALEMBANG
SUMATERA SELATAN
18 -19 Oktober 2013

Dody Firmanda
Ketua Komite Medik
RSUP Fatmawati
Jakarta

CLINICAL PATHWAYS
RSUD PALEMBANG BARI, KOTAMADYA PALEMBANG
SUMATERA SELATAN

Nama Pasien:

Diagnosis Awal: .
Aktivitas Pelayanan

.
Admisi

Umur:
Berat Badan:
Tinggi Badan:
Nomor Rekam Medis:

..kg
..cm
.
Kode ICD 10 :
Rencana rawat : hari
Tgl/Jam masuk:
Tgl/Jam keluar: Lama Rwt Kelas: Tarif/hr (Rp):
Biaya (Rp)
.
.
... hari ..
.

Rawat Inap

IGD

Hari Rawat 1

R. Rawat

IRJ

Hari Rawat 2

Hari Rawat 3

Hari Rawat 4

Hari Rawat 5

Diagnosis:
Penyakit Utama
Penyakit Penyerta

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

Komplikasi

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

Asessmen Klinis:
Pemeriksaan dokter
Konsultasi


Pemeriksaan Penunjang:






Tindakan::





..
+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

..
..

+/+/+/+/+/+/-

+/+/+/+/+/+/-

+/+/+/+/+/+/-

+/+/+/+/+/+/-

+/+/+/+/+/+/-

+/+/+/+/+/+/-

+/+/+/+/+/+/-

..

+/+/+/+/+/+/-

+/+/+/+/+/+/-

+/+/+/+/+/+/-

+/+/+/+/+/+/-

+/+/+/+/+/+/-

+/+/+/+/+/+/-

+/+/+/+/+/+/-

..

28

Obat Obatan::




Pembiusan Umum Gas:


.
Pembuisan Umum Injeksi:


.
Pembiusan Regional/Lokal:


Nutrisi::
..kkal/hari
Protein .gram/hari
Mobilisasi::

Hasil (Outcome):
..
..
..
Pendidikan/Promosi
Kesehatan/Rencana
Pemulangan:


.
Varians:
Perawat (PPJP)

DPJP Admisi:
..
DPJP:

DPJP Operasi:
.
DPJP Anestesi
.............................
Verifikator:

+/+/+/+/-

+/+/+/+/-

+/+/+/+/-

+/+/+/+/-

+/+/+/+/-

+/+/+/+/-

+/+/+/+/-

..

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

+/+/-

..

+/-

+/-

+/-

+/-

+/-

+/-

+/-

..

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/-

+/+/+/..

+/+/+/..

+/+/+/

+/+/+/

+/+/+/

+/+/+/

+/+/+/

Diagnosis Akhir:

Jumlah Biaya
..
Jenis Tindakan:
Kode ICD 9 CM

Kode ICD 10

Utama

..

Penyerta

Komplikasi

..

....

...

..
..

...
.
.
..

29

Beri Nilai