LEMBAR DISCHARGE PLANNING

No. MR : Alamat :
Nama : Ruang Rawat :
Jenis Kelamin :

Tanggal MRS : Tanggal KRS :

I. Pasien Masuk Rumah Sakit

IGD Poli................................

1. Keluhan utama/Alasan masuk :

0C,
Suhu : Nadi: x/menit, RR: x/menit, TD: / mmHg

2. Diagnosa medis :

3. Terapi/Obat-obatan yang didapat :

II. Pasien Selama Diruang Rawat Inap

Ruangan............................

1. Keadaan umum :

0C,
Suhu : Nadi: x/menit, RR: x/menit, TD: / mmHg
2. Masalah selama dirawat
Perubahan nutrisi kurang dari kebutuhan Perubahan perfusi jaringan
Anietas Intoleransi aktifitas
Nyeri Gangguan pola tidur
Gangguan keseimbangan cairan Resiko infeksi
Dan elektrolit Resiko cedera
Perubahan persepsi sensori Lain lain .....
Kerusakan komunikasi verbal
Ketidak efektifan bersihan jalan nafas

Catatan :
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III. Pasien Keluar Rumah Sakit
1. Keadaan umum :

0C,
Suhu : Nadi: x/menit, RR: x/menit, TD: / mmHg
2. Dipulangkan dari RS dengan keadaan :

Sembuh Pulang paksa

Meneruskan dengan obat jalan Lari
Pindah ke RS lain Meninggal
3. Kontrol
a. Waktu :

b. Tempat :

4. Lanjutan perawatan di rumah ( luka operasi, pemasangan gift, pengobatan, dan lain-lain )
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5. Aturan diet/Nutrisi
Bebas Cair Rendah Garam

TKTP Lunak Rendah Lemak

Catatan :
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6. Obat-obatan yang masih diminum dan jumlahnya:
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7. Aktivitas dan Istirahat :
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8. Bawaan pulang pasien ( Hasil Lab, Foto, EGC, obat, dan lain-lainnya ) :
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9. Lain-lain
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Palangka Raya.................................................
Pasien/Keluarga Perawat

( ) ( )
1) Petunjuk Teknis Pengisian Discharge Planning
(1) No MR
Diisi sesuai nomor register/medical record pasien.
(2) Nama
Diisi sesuai nama pasien
(3) Jenis Kelamin
Diisi laki-laki atau perempuan
(4) Tanggal MRS
Sesuai pasien masuk RS
(5) Diagnosis MRS
Diisi oleh dokter berdasarkan pemeriksaan klinis
(6) Tanggal KRS
Tanggal ditetapkannya pasien pulang oleh dokter
(7) Diagnosis KRS
Diagnosis pasien berdasarkan pemeriksaan klinis setelah pasien diperbolehkan
pulang.
(8) Dipulangkan dari rumah sakit dengan keadaan terakhir
Diisi berdasarkan kondisi pasien pulang
(9) Tanggal dan Tempat Kontrol
Diisi sesuai tempat dan kontrol di mana pasien kontrol.
(10) Lanjutan Perawatan di Rumah
Diisi perawatan lanjutan sesuai diagnosis sewaktu pulang (perawatan luka, gift, dan
lain-lain).
(11) Aturan Diet
Diisi berdasarkan anjuran dari ahli gizi
(12) Obat-obat yang diminum
Diisi sesuai obat yang dibawa pulang aturannya, dosisnya, dan jumlahnya.
(13) Aktifitas dan Istirahat
Diisi sesuai advis dokter tentang kegiatannya, dan istirahatnya di rumah.
(14) Yang dibawa pulang (hasil lab, foto, EKG)
Hasil dari pemeriksaan pasien yang diperbolehkan dibawa pulang
(15) Lain-lain
Diisi hal diluar ketentuan di atas misalnya obat-obat yang distop atau dihentikan