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RM 6.

1b

RSU BINA KASIH Formulir B Nama Pasien :...................................... L/P*


Jl. TB. Simatupang No 148 CASE Nomor RM :…………………………………….......
Sunggal - Medan Tanggal Lahir :………………………………………....
MANAGER
Ruangan : Diagnosa :

Tgl/Jam CATATAN
Pelaksanaan Rencana MPP :

Nama & Ttd MPP Therapi :


Tindakan :

Monitoring :

Nama & Ttd MPP 1. Hasil Lab PK PA. Radiologi: Ronsen Scanning MRI Lainnya
2. Hasil Pemeriksaan Penunjang Lain: ..............................................................................................
3. Hasil Tindakan/Operasi : ...............................................................................................................
4. Efektifitas Obat dan Alkes : ...........................................................................................................
5. Diet/Nutrisi : …………………………………………………………………………………………………………………………….
6. Solusi Biaya/Penjaminan : .............................................................................................................

Fasilitasi, Koordinasi, Komunikasi dan Kolaborasi :

Nama & Ttd MPP DPJP Utama DPJP Lain : ....................................................................................................


Perawat Farmasist Dietisen Unit lain …………………………………………..
Keluarga RS Perujuk RS Rujukan Penjamin/Asuransi : ………………………..

Advokasi :

Nama & Ttd MPP Masalah Adm/Biaya : ..................................................................................................................


Masalah Asuhan : ........................................................................................................................
Masalah Rujukan: ........................................................................................................................
Pulang Paksa : ..............................................................................................................................

Hasil Pelayanan :

Nama & Ttd MPP


Pulang atas instruksi DPJP Rujuk Exitus
GCS .......... Pain.......... Risiko jatuh ......... Vital Sign
Tindakan lain sesuai kasus............................................................................................................
Terminasi MPP :

Kebutuhan Pemulangan Rujukan :


Nama & Ttd MPP Penunjang : ................................................................................................................................
. Transportasi : .............................................................................................................................
Layanan Lanjutan : .....................................................................................................................

Catatan Khusus :