CLINICAL PATHWAYS

SMF KESEHATAN ANAK RS HASAN SADIKIN

BAYI BERAT BADAN LAHIR SANGAT RENDAH
2010
Nama Pasien:........................................... No. Rekam Medis:...................... Tgl Lahir: .................jam:..........
Jenis Cara lahir: Berat lahir: Panjang badan Lingkar kepala Nilai Apgar
Kelamin: ...................... ........................ ...............gram ...................cm ...................cm ....................
Diagnosis Awal:.......................... Kode ICD 10:......................... Rencana rawat: 7 hari
Aktivitas pelayanan R. Rawat Tgl/jam msk: Tgl/jam klr Lama rawat Kelas Tari/hr (Rp) Biaya (Rp)
............ ............. ............. ........hari ............ .............. ....................
Hari Rawat 1 Hari Rawat 2 Hari Rawat 3
Diagnosis
 Utama ............................... ............................... ...............................
 Penyerta ............................... ............................... ...............................
 Komplikasi ............................... ............................... ...............................
Asessmen Klimis
 Pemeriksaan Dokter  (+)  (-)  (+)  (-)  (+)  (-) ....................
 Konsultasi  (+)  (-)  (+)  (-)  (+)  (-) ....................
Pemeriksaan Penunjang  Hb, Ht, L, Tr, MPT,  Tontgen Thoraks  GDS
DC  Na, K, Ca
 GDS, Na, K, Ca
 Ronthen Th
Tindakan:  Perawatan Tali  Perawatan Tali  Perawatan Tali pusat .....................
pusat pusat ........................... ....
 ...........................  ...........................
Obat-Obatan  Inj Vit K1 1 mg IM
Nutrisi  Initial feeding
 Partial parenteral
nutrition
Mobiliasi 
Hasil (outcome)
 Kesadaran  (+)  (-)  (+)  (-)  (+)  (-)
 Ikterus  (+)  (-)  (+)  (-)  (+)  (-)
 Nadi  (+)  (-)  (+)  (-)  (+)  (-)
 Respirasi  (+)  (-)  (+)  (-)  (+)  (-)
 Suhu  (+)  (-)  (+)  (-)  (+)  (-)
Pendidikan/Rencana  Perawatan bayi dan
Pemulangan : tali pusat
 .......................
Varians: ...................................... ...................................... ......................................
...................................... ...................................... ......................................

Jumlah Biaya
Nama Perawat Diagnosis Akhir ICD 10 Jenis tindakan ICD-9 CM
....................................  Utama ........................................ ...........  Visite/konsul Anestesi 89.0
Nama Dokter  Penyerta ........................................ ...........  Viste/ Konsul Pem. Fisik 89.7
.................................... ........................................ ...........  Pem. Mikroskop darah 90.5
Nama Pelaksana  Komplik ........................................ ...........  ASI 99.98
Verifikasi asi ........................................ ...........  Injeksi obat Vit. K1 99.2
.................................... ........................................ ........... ........................................ ...........