Clinical Pathways

Activity based cost
CLINICAL PATHWAYS & CASEMIX Tahun :

RUMAH SAKIT UMUM DAERAH SUKAMARA
Alamat : Jalan Tjilik Riwut KM. 5,5 Sukamara Kode Pos 74172
Telpon. (0532) 26752 Faximile. (0532) 26753 CP. DHF
Nama Pasien : Umur : Berat badan : Tinggi badan : Nomor Rekam Medis :
tahun kg cm
Diagnosis awal : Demam Berdarah Dengue Kode ICD-10 : A91 Rencana hari rawat : 7 hari Biaya (Rp)
Ruang rawat : Kelas : Tarif kamar/hari (Rp) Tanggal masuk : Tanggal keluar : Lama rawat :
hari ...........................
Hari rawat : 1 2 3 4 5 6 7
KEGIATAN Hari sakit : ............. ............. ............. ............. ............. ............. .............
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
Penyerta : ............................... ............. ............. ............. ............. ............. ............. ............. ke CP penyakit tsb.
............................... ............. ............. ............. ............. ............. ............. .............
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. .............
Penegakan Diagnosis Visite DU/Sp ...........................

Konsultasi :
.............................. (lingkari) K/V K/V K/V K/V K/V K/V K/V ...........................
Pemeriksaan Penunjang :
DL *** ** ** *** *** ** **
IgM dan IgG ** ** ** ** ** **
ns1 ** ** **
................................
................................
................................ ...........................
................................
Rontgen dada (AP/RLD) ** ...........................
Tindakan : Pasang / lepas infus ***pasang ** ** ** ** ** ***lepas
Oksigen ........... l/mnt ** ** ** ** ** **

Transfusi trombosit ** ** ** ** ** **
................................ ...........................
** ** ** ** ** ** **
Obat : ivfd RL/nacl
0,9%/HES/ASERING/DEXTRAN (kolom dan
centang)
Parasetamol 3-4 x 10-15 kg/BB (centang) ** ** ** ** ** ** **
.................................
.................................
................................. ...........................
Diet (tulis/centang) ...........................
Mobilisasi (M) Fisioterapi (FT) ...........................
Luaran : Febris (tulis)
Perdarahan (centang)
Syok (centang)
.............................. (tulis)
Pemulangan :
(centang) Hidup : Seijin dokter
(centang) Pulang paksa
(centang) Dirujuk
Meninggal : (kausa)
Edukasi Penyakit : Informed consent
Problem klinis / non klinis :
Catatan: Visite, Konsultasi, Pem. Penunjang, Tindakan, Obat, diberi tanda centang (√)
Mobilisasi ditulis M, dan Fisioterapi ditulis FT Jumlah Biaya : .....................
Diagnosis akhir : Diagnosis ICD-10 Jenis Tindakan ICD-9 CM Nama Perawat :
Utama Demam Berdarah Dengue A91 Diagnosis fisik 89.03
Penyerta .................................... Visite / Konsultasi 89.01/89.07 Nama Dokter :
................................... Infus dan injeksi 99.15/99.22
................................... Transfusi trombosit 99.05
Infus koloid 99.08
Oksigen 93.96
Komplikasi Sindrom Syok Pasang DC 57.94 Verifikator :
Hematemesis .................................
................................... Pemeriksaan darah IgM - IgG 90.59
................................... Pemeriksaan darah rutin/kimia 90.59 Tanggal :
................................... .............................
keterangan
**
bisa ada atau
tidak
*** wajib ada
Tahun :
CP. DHF
or Rekam Medis :
Biaya (Rp)
...........................
ke CP penyakit tsb.
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
.....................
awat :
:
Activity based cost
CLINICAL PATHWAYS & CASEMIX
Telpon. (0532) 26752 Faximile. (0532) 26753
Nama Pasien : Umur : Berat badan : Tinggi badan :

hari kg cm
Kode ICD-10 : P21.0
Diagnosis awal : asfiksia neonatorum (asfiksia berat)Tarif kamar/hari Rencana hari rawat : 14 hari
Ruang rawat : Kelas : (Rp) Tanggal masuk : Tanggal keluar : Lama rawat : hari
Hari rawat : 1 2 3 4 5 6 7 8 9 10 11 12 13
KEGIATAN Hari sakit : .........................................................................................................................................................................
Diagnosis Utama : ............................... .........................................................................................................................................................................
Penyerta : ............................... .........................................................................................................................................................................
............................... .........................................................................................................................................................................
Komplikasi : ............................... .........................................................................................................................................................................
Penegakan Diagnosis Visite DU/Sp

Konsultasi :
.............................. K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
DR (centang) **
GDS (centang) **
LED (centang) **
CRP (centang) **
………………………………………………
………………………………………………
………………………………………………
………………………………………………
baby gram (centang) ***
……………………………………….
Tindakan : resusitasi neonatus (centang) ***
VTP 10 lpm(o2 100%) (centang) ***
CPAP (centang) *** *** *** *** *** *** *** *** *** *** *** *** ***
o2 headbox 10 lpm (centang) ** ** ** ** ** ** ** ** ** ** ** ** **
O2 NK 1-3 lpm (centang) ** ** ** ** ** ** ** ** ** ** ** ** **
……………………..
rawat dalam inkubator (centang) *** *** *** *** *** *** *** *** *** *** *** *** ***
pasang/lepas infus (tulis) ***pasang
perawatan tali pusat (centang)
……………………..
ivfd D10% (centang)
……………………..
Obat : epinefrin 0,1-0,3 ml/KgBB/x (centang) **
inj vit K 1 mg (centang) ***
salep mata ODS (centang) ***
inj ampisilin 100 mg/kgbb (centang) ** ** ** ** ** ** ** ** ** ** ** ** **
inj gentamisin 5 mg/kgBB (centang) ** ** ** ** ** ** ** ** ** ** ** ** **
………………………
………………………
………………………
Diet (tulis/centang)
Mobilisasi (M) Fisioterapi (FT)
Luaran : kesadaran (tulis)
keadaan umum (tulis)
febris (centang)
perdarahan (centang)
kejang (centang)
sesak napas (centang)
sianosis (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Catatan: Visite, Konsultasi, Pem. Penunjang, Tindakan, Obat, diberi tanda centang (√) Jumlah
Mobilisasi ditulis M, dan Fisioterapi ditulis FT Biaya :
Diagnosis akhir : Diagnosis ICD-10 Jenis Tindakan ICD-9 CM Jenis Tindakan ICD-9 CM
Utama asfiksia neonatorum (asfiksia berat) P21.0 Diagnosis fisik 89.03
Penyerta .................................... Visite / Konsultasi 89.01/89.07
................................... .................................
................................... .................................
................................... Oksigen 93.96
Komplikasi ................................... .................................
................................... .................................
Pemeriksaan darah
................................... rutin/kimia 90.59
................................... .............................
................................... .............................
keterangan
**
bisa ada atau
tidak
***
wajib ada
Tahun :
CP: asfiksia
neonatorum
(asfiksia berat)
Nomor Rekam Medis :
Biaya (Rp)
...........................
14
.............
.............
............. ke CP penyakit
............. tsb.
.............
...........................
K/V ...........................
...........................
...........................
***
**
**
*** ...........................
***lepas
** ...........................
**
...........................
...........................
mlah
ya : .....................
Nama Perawat :
Nama Dokter :
Verifikator :
Tanggal :
Activity based cost
Alamat : Jalan Tjilik Riwut KM. 5,5 Sukamara Kode Pos 74172 CP: asfiksia neonator
Telpon. (0532) 26752 Faximile. (0532) 26753 (asfiksia ringan)

hari kg cm
Diagnosis awal : asfiksia neonatorum (asfiksia ringan) Kode ICD-10 : P21.1 Rencana hari rawat
Lama: rawat
3 hari
: Biaya (Rp)
Ruang rawat : Kelas : Tarif kamar/hari (Rp) Tanggal masuk : Tanggal keluar : hari
...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
............................... ............. ............. ............. ............. ............. ............. .............
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
.............................. K/V K/V K/V K/V K/V K/V K/V K
V ...........................
DR (centang) ** ** **
GDS (centang) ** ** **
………………………………………………
………………………………………………
………………………………………………
……………………………………………… ...........................
………………………………………………
………………………………………………
baby gram (jika diperlukan) (centang) **
………………………………………. ...........................
O2 NK 1-3 lpm (centang) **
perawatan tali pusat (centang) *** *** ***
……………………..
…………………….. ...........................
……………………..
……………………..
……………………..
salep mata ODS (centang) ***
Obat : ………………………
………………………
………………………
……………………… ...........................
………………………
………………………
………………………
………………………
febris (centang)
kejang (centang)
sianosis (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Catatan: Visite, Konsultasi, Pem. Penunjang, Tindakan, Obat, diberi tanda centang (√) .....................
Mobilisasi ditulis M, dan Fisioterapi ditulis FT Nama Perawat :
Diagnosis akhir : Diagnosis ICD-10 Jenis Tindakan
Utama asfiksia neonatorum (asfiksia ringan) P21.1 Diagnosis fisik
Penyerta .................................... Visite / Konsultasi Nama Dokter :
................................... Infus dan injeksi
................................... .................................
................................... .................................
................................... Oksigen
Komplikasi ................................... ................................. Verifikator :
................................... .................................
................................... Pemeriksaan darah rutin/kimia
................................... ............................. Tanggal :
................................... .............................
keterangan
**
bisa ada atau
tidak
***
wajib ada
un :
CP: asfiksia neonatorum

(asfiksia ringan)
Biaya (Rp)
...........................
ke CP penyakit tsb.
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
.....................
ma Perawat :
ma Dokter :
ifikator :
ggal :
Activity based cost
Alamat : Jalan Tjilik Riwut KM. 5,5 Sukamara Kode Pos 74172 CP: asfiksia neonatorum
Telpon. (0532) 26752 Faximile. (0532) 26753 (asfiksia sedang)

hari kg cm
Diagnosis awal : asfiksia neonatorum (asfiksia sedang) Kode ICD-10 : P21.1 Rencana hari rawat
Lama: rawat
7 hari
: Biaya (Rp)
...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
............................... ............. ............. ............. ............. ............. ............. .............
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
V ...........................
DR (centang) **
GDS (centang) **
LED (centang) **
CRP (centang) **
…………………………………………
………………………………………… ...........................
…………………………………………
…………………………………………
baby gram (jika diperlukan) (centang) **
………………………………………. ...........................
o2 headbox 10 lpm (centang) **
O2 NK 1-3 lpm (centang) ***
CPAP (centang) **
rawat dalam inkubator (centang) ** ...........................
pasang/lepas infus (tulis) **pasang ** ** ** ** ** **lepas
perawatan tali pusat (centang) *** *** *** *** *** *** ***
……………………..
ivfd D10% (centang) ** ** ** ** ** ** **
Obat : salep mata ODS (centang) ***
inj ampisilin 100 mg/kgbb (centang) ** ** ** ** ** ** **
inj gentamisin 5 Mg/KgBB (centang) ** ** ** ** ** ** **
……………………… ...........................
………………………
………………………
………………………
………………………
febris (centang)
kejang (centang)
sianosis (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
.....................
Mobilisasi ditulis M, dan Fisioterapi ditulis FT
Diagnosis akhir : Diagnosis ICD-10 Jenis Tindakan Nama Perawat :
Utama asfiksia neonatorum (asfiksia sedang) P21.1 Diagnosis fisik
................................... .............................
................................... .............................
................................... Oksigen
................................... .................................
................................... ............................. Tanggal :
................................... .............................
keterangan
**
bisa ada atau
tidak
***
wajib ada
un :
CP: asfiksia neonatorum

(asfiksia sedang)
Biaya (Rp)
...........................
ke CP penyakit tsb.
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
.....................
ma Perawat :
ma Dokter :
ifikator :
ggal :
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753 CP: TB anak

hari kg cm
Diagnosis awal : TB Kode ICD-10 : Rencana hari rawat : 7 hari Biaya (Rp)
...........................
Hari rawat : 1 2 3 4 5 6 7
KEGIATAN Hari sakit : ...........................................................................................
Diagnosis Utama : ............................... ...........................................................................................
Penyerta : ............................... ........................................................................................... ke CP penyakit tsb.
............................... ...........................................................................................
Komplikasi : ............................... ...........................................................................................

Konsultasi :
.............................. K/V K/V K/V K/V K/V K/V K/V K ...........................
V
darah lengkap (centang) ***
GDS (centang) ***
BTA (sputum/bilas lambung) (centang) **
uji tuberkulin* (centang) **
………………………………………………
……………………………………………… ...........................
………………………………………………
………………………………………………
Rontgen dada (centang) ***
rontgen tulang (jika diperlukan) (centang) ** ...........................
Tindakan : pasang/lepas infus (centang) ***pasang ***lepas
………………………
………………………
** ** ** ** ** ** **
ivfd RL/nacl 0,9%/ (D5 1/2NS) / (kolom dan
(D51/4NS) / KAEN 3A/ KAEN 3B centang)
Obat : isoniazid (7-15 mg/kgBB) (centang) *** *** *** *** *** *** ***
rifampisin (10-20 mg/kgBB) (centang) *** *** *** *** *** *** ***
pirazinamid (30-40 mg/kgBB) (centang) *** *** *** *** *** *** ***
Etambutol (15-25 mg/kgBB) (centang) ** ** ** ** ** ** ** ...........................
streptomisin (15-40 mg/kgBB) (centang) ** ** ** ** ** ** **
………………………
………………………
………………………
………………………
………………………
………………………
febris (centang)
defisit neurologis (centang)
………………………
………………………
………………………
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
.....................
Mobilisasi ditulis M, dan Fisioterapi ditulis FT .....................
Diagnosis akhir : Diagnosis ICD-10 Jenis Tindakan Nama Perawat :
Utama TB A 15.3 Diagnosis fisik
................................... .................................
................................... .................................
................................... Oksigen
................................... .................................
Pemeriksaan darah
................................... rutin/kimia
................................... ............................. Tanggal :
................................... .............................
keterangan
**
bisa ada atau
tidak
***
wajib ada
reagen belum
tersedia di
* RSUD
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753 CP: TB (dewasa)

hari kg cm
Diagnosis awal : TB Kode ICD-10 : Rencana hari rawat
Lama: rawat
7 hari
: Biaya (Rp)
...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
............................... ............. ............. ............. ............. ............. ............. .............
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
.......................... (lingkari) K/V K/V K/V K/V K/V K/V K/V K
V ...........................
GDS (centang) ***
BTA (centang) *** ***
kimia darah : (centang) **
………………………………………………
……………………………………………… ...........................
………………………………………………
………………………………………………
Rontgen dada (centang) ***
rontgen tulang (jika diperlukan) (centang) ** ...........................
………………………
………………………
ivfd RL/nacl 0,9%/ (D5 ** ** ** ** ** ** **
1/2NS) / (D51/4NS) / KAEN (kolom dan
3A/ KAEN 3B centang)
Obat : isoniazid (7-15 mg/kgBB) (centang) *** *** *** *** *** *** ***
rifampisin (10-20 mg/kgBB) (centang) *** *** *** *** *** *** ***
pirazinamid (30-40 mg/kgBB) (centang) *** *** *** *** *** *** ***
Etambutol (15-25 mg/kgBB) (centang) *** *** *** *** *** *** *** ...........................
streptomisin (15-40 mg/kgBB) (centang) ** ** ** ** ** ** **
OAT (dewasa) (centang) *** *** *** *** *** *** ***
………………………
………………………
………………………
………………………
………………………
febris (centang)
………………………
………………………
………………………
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
.....................
Diagnosis akhir : Diagnosis ICD-10 Jenis Tindakan ICD-9 Nama Perawat :
Utama TB A 15.3 Diagnosis fisik
................................... .................................
................................... .................................
................................... Oksigen
................................... .................................
................................... ............................. Tanggal :
................................... .............................
keterangan
**
bisa ada atau
tidak
***
wajib ada
un :
CP: TB (dewasa)
Biaya (Rp)
...........................
ke CP penyakit tsb.
...........................
...........................
...........................
...........................
...........................
...........................
...........................
.....................
.....................
ma Perawat :
ma Dokter :
ifikator :
ggal :
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753 CP: ikterus neonatorum

hari kg cm
Diagnosis awal : ikterus neonatorum Kode ICD-10 : P59.9
Tarif kamar/hari Rencana hari rawat : 3 hari Biaya (Rp)
Ruang rawat : Kelas : (Rp) Tanggal masuk : Tanggal keluar : hari
...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ...........................................................................................
............................... ...........................................................................................
Komplikasi : ............................... ...........................................................................................

Konsultasi :
V ...........................
DR (centang) **
bilirubin total (centang) **
bilirubin direk (centang) **
GDS (centang) **
golongan darah & rhesus (centang) **
……………………………………………… ...........................
………………………………………………
………………………………………………
Baby gram (jika diperlukan) (centang) **
………………………………………. ...........................
Tindakan : pasang/lepas infus (centang) **pasang **lepas
fototerapi (centang) ** ** **
transfusi tukar (centang) ** ** **
………………………
……………………… ...........................
………………………
………………………
……………………..
ivfd D10% (centang) ** ** **
(centang) *** *** ***
po asam ursodioksikolat 15-25 mg/KgBB/hari
Obat : *** *** ***
………………………
………………………
……………………… ...........................
febris (centang)
kejang (centang)
sianosis (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Utama ikterus neonatorum P59.9 Diagnosis fisik
................................... .................................
................................... .................................
................................... Oksigen
................................... .................................
Pemeriksaan darah
................................... rutin/kimia
................................... ............................. Tanggal :
................................... .............................
keterangan
**
bisa ada atau
tidak
***
wajib ada
hun :
P: ikterus neonatorum
Biaya (Rp)
...........................
ke CP penyakit tsb.
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
.....................
ma Perawat :
ma Dokter :
Activity based cost
Alamat : Jalan Tjilik Riwut KM. 5,5 Sukamara Kode Pos 74172 CP: Diare akut
Telpon. (0532) 26752 Faximile. (0532) 26753 anak

hari kg cm
Diagnosis awal : diare akut Kode ICD-10 : A09.9 Rencana hari rawat : 7 hari Biaya (Rp)
...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ...........................................................................................
............................... ...........................................................................................
Komplikasi : ............................... ...........................................................................................

Konsultasi :
V
GDS (centang) **
feses lengkap (centang) ***
……………………………………………… (centang)
………………………………………………
Rontgen dada (jika diperlukan) (centang) **
………………………
………………………
** ** ** ** ** ** **
(D51/4NS) / KAEN 3A/ KAEN 3B/asering centang)
** ** ** ** ** ** **
(D51/4NS) / KAEN 3A/ KAEN 3B/asering centang)
oralit (centang) ** ** ** ** ** ** **
suplemen zinc (usia<6bln :5 mg, >6 bln :
Obat : 10 mg, >1thn: 20 mg/hari) (selama 10
*** *** *** *** *** *** ***
hari) (centang)
probiotik (centang) ** ** ** ** ** ** **
antibiotik (selektif): (centang) ** ** ** ** ** ** **
antiamoeba: (centang) ** ** ** ** ** ** ** ...........................

………………………
………………………
………………………
………………………
febris (centang)
kejang (centang)
………………………
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Diagnosis akhir : Diagnosis ICD-10 Jenis Tindakan ICD-9
Utama Diare akut (anak) A09.9 Diagnosis fisik Nama Perawat :
Penyerta .................................... Visite / Konsultasi
................................... Infus dan injeksi Nama Dokter :
................................... .............................
................................... .............................
................................... Oksigen
Komplikasi ................................... .............................
................................... .................................
Pemeriksaan darah Verifikator :
................................... rutin/kimia
................................... .............................
................................... ............................. Tanggal :
keterangan
**
bisa ada atau
tidak
***
wajib ada
Activity based cost
CP: Kejang Demam
Telpon. (0532) 26752 Faximile. (0532) 26753 Sederhana

hari kg cm
Diagnosis awal : Kejang Demam Sederhana Kode ICD-10 : R56.0 Rencana hari rawat : 5 hari Biaya (Rp)
...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ...........................................................................................
............................... ...........................................................................................
Komplikasi : ............................... ...........................................................................................

Konsultasi :
V
GDS (centang) ***
feses lengkap (centang) **
urin lengkap (centang) **
………………………………………………
………………………
………………………
** ** ** ** **
ivfd RL/nacl 0,9%/ (D5 1/2NS) / (D51/4NS) / KAEN (kolom dan
** ** ** ** **
ivfd RL/nacl 0,9%/ (D5 1/2NS) / (D51/4NS) / KAEN (kolom dan
Obat : diazepam per rektal 5 mg/10 mg (centang) ** ** ** ** **
diazepam iv 0,2-0,5 mg/kgBB iv (centang) ** ** ** ** **
inj phenobarbital 30 mg/50 mg/75 IM (loading dose) (centang) ***
inj parasetamol 10-15 mg/KgBB iv (centang) ** ** ** ** ** ...........................

antibiotik…………… (centang) ** ** ** ** **
po diazepam 0,3-0,5 mg/KgBB (centang) *** ** ** ** **
………………………………………………
………………………………………………
………………………………………………
………………………………………………
febris (centang)
kejang (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Utama kejang demam Sederhana Diagnosis fisik
................................... .............................
................................... .............................
................................... Oksigen
Komplikasi ................................... ............................. Verifikator :
................................... .................................
Pemeriksaan darah
................................... rutin/kimia
................................... ............................. Tanggal :
................................... .............................
keterangan
**
bisa ada atau
tidak
***
wajib ada
Tahun :
CP: Kejang Demam

Sederhana
Biaya (Rp)
...........................
ke CP penyakit tsb.
...........................
...........................
...........................
...........................
...........................
.....................
Nama Perawat :
Nama Dokter :
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753

hari kg cm
Diagnosis awal :Demam Tifoid Kode ICD-10 : A01.0 Rencana hari rawat
Lama: rawat
7 hari
:
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
Penyerta : ............................... ............. ............. ............. ............. ............. ............. .............
............................... ............. ............. ............. ............. ............. ............. .............
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
.............................. K/V K/V K/V K/V K/V K/V K/V
ig M salmonela (centang) **
widal (centang) **
..............................
..............................
foto thorax (jika diperlukan) (centang) **
..............................
..............................

………………………
………………………
** ** ** ** ** ** **
inj parasetamol 10-15 mg/KgBB iv (centang) ** ** ** ** ** ** **
inj atau oral kloramfenikol 100
Obat : mg/kg/hari dibagi 4 dosis selama 10-14 (centang)
*** *** *** *** *** *** ***
hari (centang)
inj ceftriaxone 80-100 mg/kgBB/12 jam (centang) ** ** ** ** ** ** **
………………………
………………………
………………………
………………………
………………………
………………………
febris (centang)
kejang (centang)
ikterus (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Utama Demam Tifoid A01.0 Diagnosis fisik
................................... .............................
................................... .............................
................................... Oksigen
Komplikasi ................................... .............................
................................... .................................
................................... .............................
................................... .............................
keterangan
**
bisa ada atau
tidak
***
wajib ada
Tahun :
CP: Demam Tifoid

anak
Biaya (Rp)
...........................
ke CP penyakit tsb.
...........................
K ...........................
V
...........................
...........................
...........................
.....................
Nama Perawat :
Nama Dokter :
Verifikator :
Tanggal :
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753

hari kg cm
Diagnosis awal :Faringitis Akut Kode ICD-10 : J02.9 Rencana hari rawat
Lama: rawat
3 hari
:
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
Penyerta : ............................... ............. ............. ............. ............. ............. ............. .............
............................... ............. ............. ............. ............. ............. ............. .............
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
.............................. K/V K/V K/V K/V K/V K/V K/V
DR (centang) ***
………………………
………………………
………………………
………………………
………………………
………………………
………………………
………………………
** ** **
inj parasetamol 10-15 mg/KgBB iv (centang) ** ** **
Obat : inj amoksisilin 150-200 mg/hari (centang) ** ** **
inj cefotaxime……… (centang) ** ** **
po eritromisin…….. (centang) ** ** **
po azitromisin 10 mg/kgBB/hari (centang) ** ** **
………………………
………………………
………………………
febris (centang)
kejang (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Utama Faringitis Akut J02.9 Diagnosis fisik
................................... .............................
................................... .............................
................................... Oksigen
Komplikasi ................................... .............................
................................... .................................
................................... .............................
................................... .............................
keterangan
**
bisa ada atau
tidak
***
wajib ada
Tahun :
CP: Faringitis Akut

(anak)
Biaya (Rp)
...........................
ke CP penyakit tsb.
...........................
K ...........................
V
...........................
...........................
...........................
.....................
Nama Perawat :
Nama Dokter :
Verifikator :
Tanggal :
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753

hari kg cm
Diagnosis awal :Bronkitis Akut Kode ICD-10 : J20.9 Rencana hari rawat
Lama: rawat
5 hari
:
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
Penyerta : ............................... ............. ............. ............. ............. ............. ............. .............
............................... ............. ............. ............. ............. ............. ............. .............
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
.............................. K/V K/V K/V K/V K/V K/V K/V
………………………
………………………
………………………
………………………
foto thorax (jika diperlukan) (centang) **
………………………
Tindakan : pasang/lepas infus (centang) ***pasang ** ** ** ***lepas
………………………
………………………
** ** ** ** **
inj parasetamol 10-15 mg/KgBB iv (centang) ** ** ** ** **
Obat : inj ampisilin sulbaktam 100 mg/kg/hari (centang) ** ** ** ** **
inj cefotaxime 50-100 mg/kgBB/hari (centang) ** ** ** ** **
inj ceftriaxone 50-100 mg/kgBB/hari (centang) ** ** ** ** **
po expektoran/mukolitik………………. (centang) ** ** ** ** **
nebulizer…………………….. (centang) ** ** ** ** **
………………………
………………………
………………………
febris (centang)
kejang (centang)
sesak napas
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Utama Bronkitis Akut J20.9 Diagnosis fisik
................................... .............................
................................... .............................
................................... Oksigen
Komplikasi ................................... .............................
................................... .................................
................................... .............................
................................... .............................
keterangan
**
bisa ada atau
tidak
***
wajib ada
Tahun :
CP: Bronkitis Akut

(anak)
Biaya (Rp)
...........................
ke CP penyakit tsb.
...........................
K
V ...........................
...........................
...........................
.....................
Nama Perawat :
Nama Dokter :
Verifikator :
Tanggal :
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753 CP: ISK (anak)

hari kg cm
Diagnosis awal :Faringitis Akut Kode ICD-10 : N39.0 Rencana hari rawat
Lama: rawat
7 hari
: Biaya (Rp)
...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
............................... ............. ............. ............. ............. ............. ............. .............
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
.............................. K/V K/V K/V K/V K/V K/V K/V K...........................
V
DR (centang) ***
GDS (centang) **
urin rutin (centang) ***
………………………
………………………
………………………
………………………
………………………
………………………
** ** ** ** ** ** **
po amoksilin 20-40 mg/kgBB/hari (centang) ** ** ** ** ** ** **
Obat : inj gentamisin 5 mg/kgBB (centang) ** ** ** ** ** ** **
inj cefotaxime 50-100 mg/kgBB/hari (centang) ** ** ** ** ** ** **
………………………
……………………… ...........................
………………………
………………………
………………………
febris (centang)
kejang (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Utama Infeksi Saluran Kemih N39.0 Diagnosis fisik
................................... .............................
................................... .............................
................................... Oksigen
Komplikasi ................................... ............................. Verifikator :
................................... .................................
................................... ............................. Tanggal :
................................... .............................
keterangan
**
bisa ada atau
tidak
***
wajib ada
Tahun :
CP: ISK (anak)
Biaya (Rp)
...........................
ke CP penyakit tsb.
...........................
...........................
...........................
...........................
...........................
.....................
Nama Perawat :
Nama Dokter :
Verifikator :
Tanggal :
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753

hari kg cm
Diagnosis awal : Kejang Demam kompleks Kode ICD-10 : R56.0
Tarif kamar/hari Rencana hari rawat : 5 hari
Ruang rawat : Kelas : (Rp) Tanggal masuk : Tanggal keluar : hari
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
Penyerta : ............................... ............. ............. ............. ............. ............. ............. .............
............................... ............. ............. ............. ............. ............. ............. .............
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
.............................. K/V K/V K/V K/V K/V K/V K/V
GDS (centang) ***
urin lengkap (centang) **
………………………………………………
………………………
………………………
** ** ** ** **
ivfd RL/nacl 0,9%/ (D5 1/2NS) / (D51/4NS) / KAEN 3A/ (kolom dan
KAEN 3B centang)
** ** ** ** **
ivfd RL/nacl 0,9%/ (D5 1/2NS) / (D51/4NS) / KAEN 3A/ (kolom dan
KAEN 3B centang)
Obat : diazepam per rektal 5 mg/10 mg (centang) ** ** ** ** **
diazepam iv 0,2-0,5 mg/kgBB iv (centang) ** ** ** ** **
inj phenobarbital 30 mg/50 mg/75 IM SD (centang) ***
inj parasetamol 10-15 mg/KgBB iv (centang) ** ** ** ** **
inj ceftriaxone 80-100 mg/KgBB/Hari (centang) ** ** ** ** **
po.phenobabital 3-5 mg/Kg BB/hari (centang) ** ** ** ** **
po asam valproat 15-40 mg/KgBB/hari dlm 2-3 dosis (centang) ** ** ** ** **
………………………………………………
………………………………………………
………………………………………………
Mobilisasi (M) Fisioterapi (FT) *)
febris (centang)
kejang (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Edukasi Penyakit : Informed consent (centang)
Problem klinis / non klinis : (centang)
*) Mobilisasi ditulis M, dan Fisioterapi ditulis FT
Utama kejang demam Kompleks R56.0 Diagnosis fisik
................................... .............................
................................... .............................
................................... Oksigen
Komplikasi ................................... .............................
................................... .................................
Pemeriksaan darah
................................... rutin/kimia
................................... .............................
................................... .............................
keterangan
**
bisa ada atau
tidak
***
wajib ada
Tahun :
CP: Kejang Demam

kompleks
Biaya (Rp)
...........................
ke CP penyakit tsb.
...........................
K ...........................
V
...........................
...........................
...........................
.....................
Nama Perawat :
Nama Dokter :
Verifikator :
Tanggal :
Activity based cost
Alamat : Jalan Tjilik Riwut KM. 5,5 Sukamara Kode Pos 74172 CP. Abortus
Telpon. (0532) 26752 Faximile. (0532) 26753 inkompletus
tahun kg cm
Diagnosis awal : Abortus Inkompletus Kode ICD-10 : O06 Rencana hari rawat : 3 hari Biaya (Rp)
hari ...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
Penyerta : ............................... ............. ............. ............. ............. ............. ............. ............. ke CP. Penyakit tsb.
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. ............. ke CP. O.1.01

Konsultasi :
Jantung K/V K/V K/V K/V K/V K/V K/V ...........................
P. Dalam K/V K/V K/V K/V K/V K/V K/V ...........................
Anestesi K/V K/V K/V K/V K/V K/V K/V ...........................
................ ...........................
...........................
Darah rutin **
HIV dan Hbsag **
golongan darah, rhesus **
................................
................................ ...........................
................................
................................
USG ***
pemeriksaan ginekologis ***
................................
................................
................................ ...........................
**pasang **lepas
Tindakan : pasang/lepas infus
**
Oksigen ........... l/mnt
kuretase **
................................
................................
................................
................................
................................ ...........................
** ** **
Obat : ivfd RL/nacl 0,9%/ D5%/
D10%/WIDA HES (kolom dan
centang)
po amoksilin 3x500 mg ** ** **
po Metilergometrin 3x1 ** ** **
po Asam Mefenamat 3x500 mg ** ** **
................................
................................
................................
................................
................................ ...........................
Luaran : Kesadaran (tulis)
Syok (centang)
Luka operasi (tulis)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Catatan: Visite, Konsultasi, Pem. Penunjang, Tidakan, Obat, diberi tanda centang (√)
Utama Abortus Inkompletus O06 Diagnosis fisik 89.26
Penyerta ............................. Visite / Konsultasi 89.01/89.7 Nama Dokter :
............................. Infus dan injeksi 99.1
............................. Kuretase 69.09
................................... Oksigen 93.96 Verifikator :
Komplikasi ................................... .............................
................................... .............................
................................... Pemeriksaan darah rutin 90.5 Tanggal :
................................... .............................
keterangan:
** bisa ada atau tidak
*** wajib ada
Activity based cost
Alamat : Jalan Tjilik Riwut KM. 5,5 Sukamara Kode Pos 74172 CP. Abortus
Telpon. (0532) 26752 Faximile. (0532) 26753 imminens
tahun kg cm
Diagnosis awal : Abortus Imminens Kode ICD-10 : O20.0 Rencana hari rawat : 7 hari Biaya (Rp)
Ruang rawat : Kelas : Tarif kamar/hari (R Tanggal masuk : Tanggal keluar : Lama rawat :
hari ...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ...........................................................................................
Penyerta : ............................... ........................................................................................... ke CP. Penyakit tsb.
Komplikasi : ............................... ........................................................................................... ke CP. O.1.01

Konsultasi :
................ ...........................
...........................
Darah rutin **
CT, BT **
HIV dan Hbsag **
................................ ...........................
................................
................................
USG ***
pemeriksaan ginekologis ***
................................
................................
................................ ...........................
**pasang ** ** ** ** ** **lepas
**
bed rest total *** *** *** *** *** *** ***
................................
................................
................................
................................
................................ ...........................
** ** ** ** ** ** **
Obat :
ivfd RL/nacl 0,9%/ D5%/ D10%/WIDA HES (kolom dan
centang)
po amoksilin 3x500 mg (centang) ** ** ** ** ** ** **
po Asam Mefenamat 3x500 mg (centang) ** ** ** ** ** ** **
Progesteron natural 200-400 mcg/hari pervaginam (centang) ** ** ** ** ** ** **
po Asam tranexamat 3x500 mg iv (centang) ** ** ** ** ** ** **

................................
................................
................................
................................ ...........................
Syok (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Diagnosis akhir : Diagnosis ICD-10 Jenis Tindakan ICD-9 CMNama Perawat :
Utama Abortus Imminens O20.0 Diagnosis fisik 89.26
Penyerta ................................... Visite / Konsultasi 89.01/89.7Nama Dokter :
............................. Infus dan injeksi 99.1
............................. Kuretase 69.09
Komplikasi ................................... .............................
................................... .............................
................................... .............................
keterangan:
*** wajib ada
kolom kosong/seharusnya pasien sudah pulang

Tahun :
CP. Abortus
imminens
mor Rekam Medis :
Biaya (Rp)
...........................
ke CP. Penyakit tsb.

ke CP. O.1.01
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
.....................
Perawat :
Dokter :
tor :
:
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753
Nama Pasien : Umur : Berat badan : BB Tinggi badan : CM

tahun
Diagnosis awal : HEG Kode ICD-10 : O21.0 Rencana hari rawat : 14 hari
Hari rawat : 1 2 3 4 5 6 7 8 9 10 11
KEGIATAN Hari sakit : ...............................................................................................................................................
Diagnosis Utama : ............................... ...............................................................................................................................................
Penyerta : ............................... ...............................................................................................................................................
Komplikasi : ............................... ...............................................................................................................................................

Konsultasi :
Jantung
P. Dalam
Anestesi
................
Darah rutin **
GDS **
fungsi tiroid **
elektrolit darah **
................................
................................
................................
USG **
EKG **
................................
................................
................................
**pasang ** ** ** ** ** ** ** ** ** **
**
................................
................................
................................
................................
................................
................................
** ** ** ** ** ** ** ** ** ** **
Obat : ivfd RL/nacl 0,9%/ D5%/
D10%/WIDA HES (kolom dan
centang)
Ondancentron 4 atau 8 mg drip IV (centang) ** ** ** ** ** ** ** ** ** ** **
inj ranitidine 50 mg/12 jam iv (centang) ** ** ** ** ** ** ** ** ** ** **
po Domperidone 3x 10 mg (centang) ** ** ** ** ** ** ** ** ** ** **
po antasida syr (centang) ** ** ** ** ** ** ** ** ** ** **
................................
................................
................................
................................
Syok (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Mobilisasi ditulis M, dan Fisioterapi ditulis FT Jumlah Biaya :
Diagnosis akhir : Diagnosis ICD-10 Jenis Tindakan ICD-9 CM Jenis Tindakan ICD-9
Utama Hiperemesis Gravidarum O21.0 Diagnosis fisik 89.26 .............................
................................... Visite / Konsultasi 89.01/89.
Penyerta 7 .............................
................................... Infus dan injeksi 99.1 .............................
................................... Kuretase 69.09 .............................
................................... Oksigen 93.96 .............................
Komplikasi ................................... ............................. .............................
................................... ............................. .............................
................................... Pemeriksaan darah rutin 90.5 .............................
................................... ............................. .............................
keterangan:
*** wajib ada
kolom kosong/seharusnya pasien
sudah pulang
Tahun :
CP. HEG
n: CM Nomor Rekam Medis :
4 hari Biaya (Rp)

awat :
hari ...........................
12 13 14
.......................... ........
.......................... .........
....................................... ke CP. Penyakit tsb.
.......................................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
** ** **lepas
...........................
** ** **
** ** **
** ** **
** ** **
** ** **
...........................
...........................
...........................
iaya : .....................
ICD-9 Nama Perawat :
Nama Dokter :
Verifikator :
Tanggal :
Activity based cost
Alamat : Jalan Tjilik Riwut KM. 5,5 Sukamara Kode Pos 74172 CP. Hipertensi Kronis
Telpon. (0532) 26752 Faximile. (0532) 26753 (dalam kehamilan)
tahun kg cm
Diagnosis awal : Hipertensi Kronis Kode ICD-10 : O10.0 Rencana hari rawat : 7 hari Biaya (Rp)
hari ...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
Penegakan Diagnosis Visite ...........................

Konsultasi :
ICU/HCU K/V K/V K/V K/V K/V K/V K/V ...........................
...........................
Darah rutin **
HIV, HbSag **
sgot, sgpt, asam urat, albumin **
protein urin ** ...........................

ureum, creatinin **
................................
................................
CTG **
EKG **
USG ***
................................
................................ ...........................
Tindakan : infus pasang/lepas **pasang ** ** ** ** ** **lepas
Oksigen ........... l/mnt **
DJJ *** *** *** *** *** ** **
Induksi oksitosin ** ** ** **
ekstraksi vakum ** ** ** **
Sectio cesaria ** ** ** **
................................
................................ ...........................
Obat : ivfd RL/nacl 0,9%/ D5%/ (kolom dan
** ** ** ** ** ** **
D10%/WIDA HES centang)
inj oksitosin … amp (centang) ** ** ** ** ** ** **
po Metil dopa 3x250-500 mg (centang) ** ** ** ** ** ** **
po Nifedipin 4x10 mg (centang) ** ** ** ** ** ** **
inj dexametason 1 amp/12 jm (centang) ** ** **
................................
................................ ...........................
Syok (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Utama Hipertensi Kronis O10.0 Diagnosis fisik 89.03
Penyerta ................................... Visite / Konsultasi 89.01/89.7 Nama Dokter :
................................... Infus dan injeksi 99.1
................................... Sectio cesaria 74.0
Komplikasi ................................... Induksi sintosinon 73.4
................................... Ekstraksi forceps 72.1
................................... .............................
Catatan: Lingkari K bila konsultasi, lingkari V bila visite

Centang atau lingkari Diagnosis akhir , Penyerta dan Komplikasi, serta Jenis Tindakan
*** wajib ada
kolom kosong/seharusnya
pasien sudah pulang
Tahun :
CP. Hipertensi Kronis

(dalam kehamilan)
or Rekam Medis :
Biaya (Rp)
...........................

ke CP. O.3.01
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
.....................
awat :
:
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753

tahun kg cm
Diagnosis awal : Pre Eklampsia Berat Kode ICD-10 : O14.1 Rencana hari rawat : 12 hari
hari
Hari rawat : 1 2 3 4 5 6 7 8 9 10 11
Diagnosis Utama : ............................... ...............................................................................................................................................
Penyerta : ............................... ...............................................................................................................................................
Komplikasi : ............................... ...............................................................................................................................................

Konsultasi :
Jantung K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
P. Dalam K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
Anestesi K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
ICU/HCU K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
Darah rutin **
HIV, HbSag **
CT, BT **
protein urin ***
sgot, sgpt,asam urat, albumin **
ureum, creatinin **
................................
................................
EKG **
CTG **
USG ***
................................
Tindakan : Infus pasang/lepas **pasang
Oksigen ........... l/mnt **
DJJ *** ** ** ** ** ** ** ** ** ** **
Kateter urin ** ** ** ** ** ** ** **
Induksi oksitosin ** ** ** ** ** ** ** **
ekstraksi vakum ** ** ** ** ** ** ** **
Sectio cesaria ** ** ** ** ** ** ** **
................................
................................
Obat : ivfd RL/nacl/ D5%/ (kolom dan
** ** ** ** ** ** ** ** ** ** **
inj MgSO4 8 gr 40% IM (centang) ***
po Nifedipin 10-20 mg (centang) *** *** *** *** *** *** *** *** *** *** ***
po Metil dopa 3x250-500 mg (centang) ** ** ** ** ** ** ** ** ** ** **
................................
................................
Syok (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Utama PEB O14.1 Diagnosis fisik 89.03
Penyerta ................................... Visite / Konsultasi 89.01/89.7
................................... Sectio cesaria 74.0
................................... Oksigen 93.96
................................... Pemeriksaan darah rutin 90.5
................................... .............................

*** wajib ada
Tahun :
CP. PEB
Nomor Rekam Medis :
Biaya (Rp)
hari ...........................
12
.............
.............
............. ke CP. Penyakit tsb.
.............
...........................
K/V ...........................
K/V ...........................
K/V ...........................
K/V ...........................
...........................
...........................
...........................
**lepas
**
...........................
**
***
**
...........................
...........................
...........................
.....................
Nama Perawat :
Nama Dokter :
Verifikator :
Tanggal :
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753 CP. HT Gestasional
tahun kg cm
Diagnosis awal : HT Gestasional Kode ICD-10 : O10.0 Rencana hari rawat : 7 hari Biaya (Rp)
hari ...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
ICU K/V K/V K/V K/V K/V K/V K/V ...........................
...........................
Darah rutin **
CT, BT **
HIV, HbSag ***
protein urin *** ...........................

ureum, creatinin **
...............................
...............................
EKG **
CTG **
USG ***
................................ ...........................
Tindakan : Infus pasang/lepas **pasang **lepas
Oksigen ........... l/mnt **
DJJ *** ** ** ** ** ** **
Induksi oksitosin ** ** ** **
ekstraksi vakum ** ** ** **
Sectio cesaria *** ** ** **
................................
................................
................................ ...........................
** ** ** ** ** ** **
po Metil dopa 3x250-500 mg (centang) ** ** ** ** ** ** **
po Nifedipin 10-20 mg (centang) ** ** ** ** ** ** **
................................
................................
................................ ...........................
Syok (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Utama HT Gestasional O10.O Diagnosis fisik 89.03
................................... Sectio cesaria 74.0
................................... .............................

*** wajib ada
kolom kosong/seharusnya pasien
sudah pulang
Tahun :
CP. HT Gestasional
or Rekam Medis :
Biaya (Rp)
...........................

ke CP. O.3.01
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
.....................
awat :
ter :
:
Activity based cost
CP. Kehamilan Lewat
Telpon. (0532) 26752 Faximile. (0532) 26753 Waktu
tahun kg cm
Diagnosis awal : Kehamilan Lewat Waktu Kode ICD-10 : O48 Rencana hari rawat : 12 hari Biaya (Rp)
hari ...........................
Hari rawat : 1 2 3 4 5 6 7 8 9 10 11 12
KEGIATAN Hari sakit : ........................................................................................................................................................
Diagnosis Utama : ............................... ........................................................................................................................................................
Penyerta : ............................... ............................................................................................................................................................ ke CP. Penyakit tsb.
Komplikasi : ............................... ............................................................................................................................................................

Konsultasi :
Jantung K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V ...........................
P. Dalam K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V ...........................
Anestesi K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V ...........................
ICU/HCU K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V ...........................
...........................
Darah rutin **
CT, BT **
HIV, HbSag ***
................................ ...........................
................................
................................
USG ***
CTG **
................................
................................ ...........................
Tindakan : Infus pasang/lepas **pasang ** ** ** ** ** ** ** ** ** ** **lepas
Oksigen ........... l/mnt **
DJJ *** ** ** ** ** ** ** ** ** **
ektraksi vakum ** ** ** ** ** ** ** ** ** **
Induksi sintosinon ** ** ** ** ** ** ** ** ** **
Sectio cesaria ** ** ** ** ** ** ** ** ** **
................................
................................
................................ ...........................
Obat : ivfd RL/nacl 0,9%/ D5%/ (lingkari dan
** ** ** ** ** ** ** ** ** ** ** **
inj oksitosin .. Amp (centang) ** ** ** ** ** ** ** ** ** ** ** **
po asam mefenamat 3x500 mg (centang) ** ** ** ** ** ** ** ** ** ** ** **
................................
................................
................................ ...........................
Syok (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Diagnosis akhir : Diagnosis ICD-10 Jenis Tindakan ICD-9 CM Jenis Tindakan ICD-9 CM Nama Perawat :
Utama Kehamilan Lewat Waktu O48 Diagnosis fisik 89.03
................................... Sectio cesaria 74.0
................................... .............................

*** wajib ada
pasien sudah pulang
Tahun :
CP. Kehamilan Lewat

Waktu
mor Rekam Medis :
Biaya (Rp)
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
.....................
ma Perawat :
ma Dokter :
fikator :
ggal :
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753 CP. Kehamilan Preterm
tahun kg cm
Diagnosis awal : Kehamilan Preterm Kode ICD-10 : O60 Rencana hari rawat : 12 hari Biaya (Rp)
hari ...........................
Hari rawat : 1 2 3 4 5 6 7 8 9 10 11 12
KEGIATAN Hari sakit : ............................................................................................................................................................
Diagnosis Utama : ............................... ............................................................................................................................................................
Penyerta : ............................... ............................................................................................................................................................ ke CP. Penyakit tsb.
Komplikasi : ............................... ............................................................................................................................................................ ke CP. O.3.01

Konsultasi :
Jantung K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V ...........................
P. Dalam K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V ...........................
Anestesi K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V ...........................
ICU/HCU K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V ...........................
...........................
Darah rutin **
HIV, HbSag ***
CT, BT **
................................ ...........................
................................
................................
USG ***
CTG **
................................
................................ ...........................
Oksigen ........... l/mnt **
DJJ *** *** *** *** *** *** *** *** *** *** *** ***
bed rest total *** *** *** *** *** *** *** *** *** *** *** ***
................................
................................
................................
................................
................................ ...........................
Obat : ivfd RL/nacl 0,9%/ D5%/ ** ** ** ** ** ** ** ** ** ** ** **
(lingkari dan
D10%/WIDA HES centang) ** ** ** ** ** ** ** ** ** ** ** **
inj Dexametason 5 mg/12 jam (centang) *** *** **
inj ampixilin 2g/6 jam (centang) ** ** ** ** ** ** **
po Nifedipin 3x10 mg (centang) ** ** ** ** ** ** ** ** ** ** ** **
po asam mefenamat 3 x 500 mg ** ** ** ** ** ** ** ** ** ** ** **
po histolan 3 x1 ** ** ** ** ** ** ** ** ** ** ** ** ...........................
................................
Syok (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Utama Kehamilan Preterm O60 Diagnosis fisik 89.03
................................... Sectio cesaria 74.0
................................... .............................

*** wajib ada
pasien sudah pulang
Tahun :
CP. Kehamilan Preterm
mor Rekam Medis :
Biaya (Rp)
...........................

ke CP. O.3.01
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
.....................
Perawat :
Dokter :
ator :
al :
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753 CP. Ketuban Pecah Dini
tahun kg cm
Diagnosis awal : Ketuban Pecah Dini Kode ICD-10 : O42 Rencana hari rawat : 10 hari Biaya (Rp)
hari ...........................
Hari rawat : 1 2 3 4 5 6 7 8 9 10
KEGIATAN Hari sakit : ..................................................................................................................................
Diagnosis Utama : ............................... ..................................................................................................................................
Penyerta : ............................... .................................................................................................................................. ke CP. Penyakit tsb.
Komplikasi : ............................... ..................................................................................................................................

Konsultasi :
Jantung K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V ...........................
P. Dalam K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V ...........................
Anestesi K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V ...........................
ICU/HCU K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V ...........................
...........................
Darah rutin **
HIV, HbSag ***
CT, BT **
................................ ...........................
................................
................................
USG ***
CTG **
................................
................................ ...........................
Tindakan : Infus pasang/lepas **pasang ** ** ** ** ** ** ** ** **lepas
Oksigen ........... l/mnt **
DJJ *** *** *** *** *** *** *** *** ** **
ektsraksi vakum ** ** ** ** ** ** **
Induksi sintosinon ** ** ** ** ** ** **
pemeriksaan dalam dan ins ** ** ** ** ** ** **
Sectio cesaria ** ** ** ** ** ** **
................................
................................ ...........................
Obat : ivfd RL/nacl 0,9%/ D5%/ (lingkari dan ** ** ** ** ** ** ** ** ** **
................................
................................
................................
................................ ...........................
Syok (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Diagnosis akhir : Diagnosis ICD-10 Jenis Tindakan ICD-9 CM Jenis Tindakan Nama Perawat :
Utama Ketuban Pecah Dini O42 Diagnosis fisik 89.03
................................... Sectio cesaria 74.0
................................... .............................

*** wajib ada
pasien sudah pulang
Tahun :
CP. Ketuban Pecah Dini
mor Rekam Medis :
Biaya (Rp)
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
.....................
Perawat :
Dokter :
tor :
:
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753
Nama Pasien : Umur : Berat badan : Tinggi badan : Nomor Rekam Me

tahun kg cm
Diagnosis awal : Plasenta Previa Kode ICD-10 : O44.1 Rencana hari rawat : 12 hari
hari
Hari rawat : 1 2 3 4 5 6 7 8 9 10 11 12
KEGIATAN Hari sakit : ............................................................................................................................................................
Diagnosis Utama : ............................... ............................................................................................................................................................
Penyerta : ............................... ............................................................................................................................................................
Komplikasi : ............................... ............................................................................................................................................................

Konsultasi :
Jantung K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
P. Dalam K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
Anestesi K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
HCU/ICU
Darah rutin **
HIV, HbSag ***
CT, BT **
................................
................................
................................
USG ***
CTG **
................................
Oksigen ........... l/mnt ** ** ** ** ** ** ** **
DJJ *** *** *** *** *** *** *** *** *** ***
Kateter urin ** ** ** ** ** ** ** ** ** ** ** **
transfusi darah ** ** ** ** ** ** ** ** ** ** ** **
Sectio cesaria ** ** ** ** ** ** ** ** ** ** ** **
................................
................................
................................
Obat : ivfd RL/nacl 0,9%/ D5%/ ** ** ** ** ** ** ** ** ** ** ** **
(lingkari dan
inj Dexametason 6 mg/12 jam (centang) ** ** **
po Nifedipin 3x10 mg (centang) ** ** ** ** ** ** ** ** ** ** ** **
po hystolan 3x1 (centang) ** ** ** ** ** ** ** ** ** ** ** **
................................
Syok (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Utama plasenta previa O44.1 Diagnosis fisik 89.03
................................... Sectio cesaria 74.0
................................... .............................

*** wajib ada
pasien sudah pulang
Tahun :
CP. Plasenta Previa
Nomor Rekam Medis :
Biaya (Rp)
...........................
.............
.............
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
.....................
Nama Perawat :
Nama Dokter :
Verifikator :
Tanggal :
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753

tahun kg cm
Diagnosis awal : Eklamsia Kode ICD-10 : E15 Rencana hari rawat : 15 hari
Hari rawat : 1 2 3 4 5 6 7 8 9 10 11 12 13
KEGIATAN Hari sakit : .........................................................................................................................................................................
Diagnosis Utama : ............................... .........................................................................................................................................................................
Penyerta : ............................... .........................................................................................................................................................................
Komplikasi : ............................... .........................................................................................................................................................................

Konsultasi :
Jantung K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
P. Dalam K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
Anestesi K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
ICU/HCU
Darah rutin **
CT, BT **
protein urin ***
HIV, HbSag ***
ureum, creatinin **
................................
EKG **
CTG **
USG ***
................................
Tindakan : Infus pasang/lepas **pasang ** ** ** ** ** ** ** ** ** ** ** **

DJJ ** ** ** ** ** ** ** ** ** **
Kateter urin ** ** ** ** ** ** ** ** ** **
ektraksi vakum ** ** ** ** ** ** ** ** ** **
Sectio cesaria ** ** ** ** ** ** ** ** ** **
................................
................................
................................
** ** ** ** ** ** ** ** ** ** ** ** **
D10%/HES centang)
inj MgSO4 8 gr 40% IM (centang) *** **
po Nifedipin 10-20 mg (centang) ** ** ** ** ** ** ** ** ** ** ** ** **
po Metil dopa 3x250-500 mg (centang) ** ** ** ** ** ** ** ** ** ** ** ** **
po bisoprolol 2x 2,5 mg (centang) ** ** ** ** ** ** ** ** ** ** ** ** **
................................
................................
Syok (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Utama Eklamsia E15 Diagnosis fisik 89.03
Penyerta ................................... Visite / Konsultasi 89.01/89.7
................................... Sectio cesaria 74.0
................................... Oksigen 93.96
................................... Pemeriksaan darah rutin 90.5
................................... .............................

*** wajib ada
pasien sudah pulang
Tahun :
CP. Eklamsia
Nomor Rekam Medis :
Biaya (Rp)
hari ...........................
14 15
..........................
..........................
.......................... ke CP. Penyakit tsb.
..........................
...........................
K/V K/V ...........................

K/V K/V ...........................
K/V K/V ...........................
...........................
...........................
...........................
...........................
** **lepas
...........................
** **
** **
** **
** **
...........................
...........................
...........................
.....................
Nama Perawat :
Nama Dokter :
Verifikator :
Tanggal :
Activity based cost
CP. DISPEPSIA
Telpon. (0532) 26752 Faximile. (0532) 26753
tahun kg cm
Diagnosis awal : Dispepsia Kode ICD-10 : K30 Rencana hari rawat : 5 hari Biaya (Rp)
hari ...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
......................... K/V K/V K/V K/V K/V K/V K/V ...........................
............................. K/V K/V K/V K/V K/V K/V K/V ...........................
Darah rutin **
Ureum , Kreatinin, GDS **
SGOT, SGPT **
....................
........................... ...........................
OMD **
EKG **
USG abdomen **
................................ ...........................
Tindakan : pasang/lepas infus (psg/lps) **pasang ** ** ** **lepas
o2 NK 1 lpm **
....................
....................
....................
....................
................................ ...........................
Obat : ivfd RL/nacl/ (D5 1/2NS) / ** ** ** ** **
(D51/4NS) / KAEN 3A/ KAEN (kolom dan
3B centang)
inj ranitidine …… (centang) ** ** ** ** **
inj omeprazole…. (centang) ** ** ** ** **
po antasida (centang) ** ** ** ** **
po sucralfat…. (centang) ** ** ** ** **
....................
....................
....................
.................... ...........................
Anemia (centang)
Syok (centang)
.................... (centang)
Pemulangan :
(centang) Dirujuk
Meninggal : (kausa)
Diagnosis akhir : Diagnosis ICD-10 Jenis Tindakan ICD-9 CM Jenis Tindakan
Utama dispepsia fungsional K30 Diagnosis fisik 89.03 ...................................
................................... Visite / Konsultasi 89.01/89.07 ...................................
................................... ................................... ...................................
................................... ................................... ...................................
................................... Infus dan injeksi 99.15/99.22 ...................................
................................... Transfusi PRC 99.04 Nama Perawat :
................................... Oksigen 93.96 ...................................
................................... Pasang DC 57.94 ...................................
................................... Pasang NGT 96.33 ...................................
Penyerta ................................... EKG 89.52 Nama Dokter :
................................... OMD
................................... ...................................
Komplikasi ................................... Pemeriksaan darah rutin/kimia 90.59
................................... ................................... Verifikator :
................................... ...................................
................................... ................................... Tanggal :
................................... ...................................

*** wajib ada
pasien sudah pulang
Tahun :
CP. DISPEPSIA
or Rekam Medis :
Biaya (Rp)
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
.....................
ICD-9 CM
.................
.................
.................
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753 CP. DM
tahun kg cm
Diagnosis awal : Diabetes Melitus tipe 2 Kode ICD-10 : Rencana hari rawat : 7 hari Biaya (Rp)
hari ...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
Penyerta : ............................... ............. ............. ............. ............. ............. ............. ............. tulis komplikasi pada
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. ............. kolom hari rawat

Konsultasi :
Bedah K/V K/V K/V K/V K/V K/V K/V ...........................
Gizi Medik K/V K/V K/V K/V K/V K/V K/V ...........................
...........................
Darah rutin **
GDS **
Albumin, Asam urat **
Urin rutin **
Ureum , Kreatinin **
Na, K, Cl (untuk komplikasi) **
............................ ...........................
Rö thorax (untuk komplikasi/penyerta) **
EKG (usia > 45 tahun, atau problem jantung) **
..................................
................................ ...........................
Tindakan : Infus ........... : ....... Cc/jam **pasang ** ** ** ** ** **lepas
Regulasi gula darah ** ** ** ** ** ** **

Untuk komplikasi/penyerta: **
Oksigen ........... l/mnt ** ** ** ** ** ** **
Kateter urin (psg/lps) ** ** ** ** ** ** **
Transfusi PRC ** ** ** ** ** ** **
Pasang NGT (psg/lps) ** ** ** ** ** ** **
................................ ...........................
Obat : inj. Insulin R / 6 jam sc. ** ** ** ** ** ** **
drip Insulin ............................ ** ** ** ** ** ** **
Gliklazid ............................ ** ** ** ** ** ** **
Metformin ............................ ** ** ** ** ** ** **
Acarbose ............................ ** ** ** ** ** ** **
Gliquidon ............................ ** ** ** ** ** ** **
inj insulin……… ** ** ** ** ** ** **
.............................
.............................
............................. ...........................
Diet (tulis/centang) Diagnosis Primer
Mobilisasi (M) Fisioterapi (FT) ICD-X
Gula terkontrol (centang)
Syok (centang)
.......................... (centang) Diagnosis Sekunder
Pemulangan : ICD-X
(salah satu) BLPL / APS / Rujuk
Meninggal : (kausa)
Varian
(penyulit) Jumlah Biaya : .....................
Utama Diabetes melitus tipe 2 E11.9 Diagnosis fisik 89.03
.................... ... Visite 89.01
Penyerta .................... ... Konsultasi 89.07
.................... ... Transfusi PRC 99.04
.................... ... Infus dan injeksi 99.15/99.22
.................... ... Regulasi cepat insulin 99.17 ........................................
.................... ... Oksigen 93.96 ...................................
.................... ... Pasang DC 57.94 Nama Perawat :
Komplikasi .................... ... Pasang NGT 96.33
.................... ... EKG 89.52 Nama Dokter :
.................... ... Pemeriksaan darah rutin/kimia 90.59
.................... ... Rontgen dada 87.44
.................... ... USG Ginjal 88.75
.................... ... Rehidrasi / Koreksi hipokalemia 99.18 Verifikator :
.................... ... ...................................
.................... ... ................................... Tanggal :
.................... ... ...................................
Penyakit penyerta / komplikasi yang perlu penanganan lagi, diikuti dengan Clinical Pathway penyakit tersebut
Catatan: Lingkari K bila konsultasi, lingkari V bila visite (bila rawat bersama / konsultasi)
keterangan
**
bisa ada
atau tidak
*** wajib ada
hun :
CP. DM
ekam Medis :
Biaya (Rp)
...........................
ulis komplikasi pada

kolom hari rawat
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
Diagnosis Primer
ICD-X
iagnosis Sekunder
ICD-X
.....................
ICD-9 CM
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753 CP. HT
tahun kg cm
Diagnosis awal : Hipertensi Kode ICD-10 : I10 Rencana hari rawat : 7 hari Biaya (Rp)
hari ...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
...........................
Darah rutin **
GDS **
Urin rutin **
............................ ...........................
..................................
................................ ...........................
Untuk komplikasi/penyerta: ** ** ** ** ** ** **
Oksigen ........... l/mnt ** ** ** ** ** ** **
Transfusi PRC ** ** ** ** ** ** **
................................ ...........................
Obat : antihipertensi
............................ ** ** ** ** ** ** **
............................
............................
............................
............................
.............................
.............................
.............................
............................. ...........................
Syok (centang)
Pemulangan : ICD-X
Meninggal : (kausa)
Varian
Utama Hipertensi I10 Diagnosis fisik 89.03 ...................................
.................... .... Visite 89.01 ...................................
Penyerta .................... .... Konsultasi 89.07 ...................................
.................... .... Transfusi PRC 99.04 ...................................
Infus dan injeksi 99.15/99. ...................................

.................... .... 22
.................... .... Regulasi cepat insulin 99.17 ...................................
.................... .... Oksigen 93.96 ...................................
.................... .... Pasang DC 57.94 Nama Perawat :
Komplikasi .................... .... Pasang NGT 96.33
.................... .... EKG 89.52 Nama Dokter :
.................... .... Pemeriksaan darah rutin/kimia 90.59
.................... .... Rontgen dada 87.44
.................... .... USG Ginjal 88.75
.................... .... Rehidrasi / Koreksi hipokalemia 99.18 Verifikator :
.................... .... ...................................
.................... .... ................................... Tanggal :
.................... .... ...................................
**
bisa ada atau
tidak
*** wajib ada
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753
tahun kg cm
Diagnosis awal : Iskemia Heart Disease Kode ICD-10 : I25.9 Rencana hari rawat : 7 hari
hari
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
Penyerta : ............................... ............. ............. ............. ............. ............. ............. .............
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
Bedah K/V K/V K/V K/V K/V K/V K/V
Gizi Medik K/V K/V K/V K/V K/V K/V K/V
ICU/HCU K/V K/V K/V K/V K/V K/V K/V
..................................
Darah rutin **
GDS **
Urin rutin **
kolesterol total, Tg **
............................
..................................
................................
Untuk komplikasi/penyerta:
Oksigen ........... l/mnt ** ** ** ** ** ** **
Transfusi PRC ** ** ** ** ** ** **
................................
Obat : antikoagulan/antiplatelet
............................
............................
............................
antihipertensi ............................
............................
antihiperkolesterolemia
.............................
.............................
Syok (centang)
.......................... (centang)
Pemulangan :
Meninggal : (kausa)
Varian
(penyulit) Jumlah Biaya :
Utama Ischemic heart disease I25.9 Diagnosis fisik 89.03 ...................................
.................... ... Visite 89.01 ...................................
Penyerta .................... ... Konsultasi 89.07 ...................................
.................... ... Transfusi PRC 99.04 ...................................
.................... ... Infus dan injeksi 99.15/99.22 ...................................
.................... ... Oksigen 93.96 ...................................
.................... ... EKG 89.52 Nama Dokter :
.................... ... Pemeriksaan darah rutin/kimia 90.59
.................... ... Rontgen dada 87.44
.................... ... USG Ginjal 88.75
.................... ... Rehidrasi / Koreksi hipokalemia 99.18 Verifikator :
.................... ... ...................................
.................... ... ................................... Tanggal :
.................... ... ...................................
**
bisa ada atau
tidak
*** wajib ada
Tahun :
CP. IHD
Nomor Rekam Medis :
Biaya (Rp)
...........................
tulis komplikasi pada

kolom hari rawat
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
Diagnosis Primer
ICD-X
Diagnosis Sekunder
ICD-X
.....................
is Tindakan ICD-9 CM
........................
........................
........................
........................
........................
..........................
........................
:
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753 CP. Dislipidemia
tahun kg cm
Diagnosis awal : Dislipidemia Kode ICD-10 : E78.5 Rencana hari rawat : 7 hari Biaya (Rp)
hari ...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
ICU K/V K/V K/V K/V K/V K/V K/V ...........................
...........................
Darah rutin **
GDS **
Urin rutin **
kolesterol total, TG **
............................ ...........................
..................................
................................ ...........................
Oksigen ........... l/mnt **
Kateter urin (psg/lps) **
Transfusi PRC **
Pasang NGT (psg/lps) **
................................ ...........................
Obat : anti hiperkolesterolemia
............................
............................
anti hipertriglise ............................
............................
............................
............................. ...........................
Syok (centang)
Pemulangan : ICD-X
Meninggal : (kausa)
Varian
Utama Dislipidemia E78.5 Diagnosis fisik 89.03
................... ... Visite 89.01
Penyerta ................... ... Konsultasi 89.07
................... ... Transfusi PRC 99.04
................... ... Infus dan injeksi 99.15/99.22
................... ... Regulasi cepat insulin 99.17 ........................................
................... ... Oksigen 93.96 ...................................
................... ... Pasang DC 57.94 Nama Perawat :
Komplikasi ................... ... Pasang NGT 96.33
................... ... EKG 89.52 Nama Dokter :
................... ... Pemeriksaan darah rutin/kimia 90.59
................... ... Rontgen dada 87.44
................... ... USG Ginjal 88.75
................... ... Rehidrasi / Koreksi hipokalemia 99.18 Verifikator :
................... ... ...................................
................... ... ................................... Tanggal :
................... ... ...................................
**
bisa ada atau
tidak
*** wajib ada
Tahun :
CP. Dislipidemia
r Rekam Medis :
Biaya (Rp)
...........................

kolom hari rawat
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
Diagnosis Primer
ICD-X
Diagnosis Sekunder
ICD-X
.....................
ICD-9 CM
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753

tahun kg
Diagnosis awal :Infeksi Saluran Kemih Kode ICD-10 : N39.0 Rencana hari rawat : 14 hari
Hari rawat : 1 2 3 4 5 6 7 8 9 10 11
Diagnosis Utama : ............................... ...............................................................................................................................................
Penyerta : ............................... ...............................................................................................................................................
Komplikasi : ............................... ...............................................................................................................................................

Konsultasi :
Bedah K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
Gizi Medik K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
ICU/HCU K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
...............................
Darah rutin **
GDS **
Urin rutin **
............................
..................................
................................
Tindakan : Infus ........... : ....... Cc/jam **pasang ** ** ** ** ** ** ** ** ** **
Oksigen ........... l/mnt **
Transfusi PRC **
................................
Obat : antibiotik
............................
............................
............................
............................
............................
.............................
.............................
.............................
.............................
Syok (centang)
.......................... (centang)
Pemulangan :
Meninggal : (kausa)
Varian
Utama ISK N39.0 Diagnosis fisik 89.03 ...................................
................................... Visite 89.01 ...................................
Penyerta ................................... Konsultasi 89.07 ...................................
................................... Transfusi PRC 99.04 ...................................
99.15/99.
................................... Infus dan injeksi 22 ...................................
................................... Regulasi cepat insulin 99.17 ........................................
................................... Oksigen 93.96 ...................................
................................ Pasang DC 57.94 Nama Perawat :
Komplikasi ................................... Pasang NGT 96.33

................................... EKG 89.52 Nama Dokter :
...................................
................................... Pemeriksaan darah rutin/kimia 90.59
................................... Rontgen dada 87.44
................................... USG Ginjal 88.75
................................... Verifikator :
................................... Rehidrasi / Koreksi hipokalemia 99.18
................................... ................................... Tanggal :
................................... ...................................
**
bisa ada atau
tidak
*** wajib ada
Tahun :
CP. ISK (Dewasa)
Nomor Rekam Medis :
4 hari Biaya (Rp)

awat :
hari ...........................
12 13 14
.......................................
.......................................
....................................... tulis komplikasi pada
....................................... kolom hari rawat
...........................
K/V K/V K/V ...........................

K/V K/V K/V ...........................
K/V K/V K/V ...........................
...........................
...........................
...........................
** ** **lepas
...........................
...........................
Diagnosis Primer
ICD-X
Diagnosis Sekunder
ICD-X
iaya : .....................
nis Tindakan ICD-9 CM
.........................
.........................
.........................
.........................
.........................
...........................
.........................
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753 CP. Spondiloatropati
tahun kg cm
Diagnosis awal :Spondiloatropati Kode ICD-10 : M47.9 Rencana hari rawat : 7 hari Biaya (Rp)
hari ...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
...........................
Darah rutin **
GDS **
Urin rutin **
............................ ...........................
rontgen tulang lainnya(…………………..) **
..................................
................................ ...........................
Oksigen ........... l/mnt **
Transfusi PRC **
................................ ...........................
Obat : anti inflamasi non steroid ** ** ** ** ** ** **
............................
............................
............................
analgesik ............................ ** ** ** ** ** ** **
............................
.............................
.............................
.............................
............................. ...........................
Syok (centang)
Pemulangan : ICD-X
Meninggal : (kausa)
Varian
Utama spondiloartropati M47.9 Diagnosis fisik 89.03
................................... Visite 89.01
Penyerta ................................... Konsultasi 89.07
................................... Transfusi PRC 99.04
................................... Regulasi cepat insulin 99.17 ........................................
................................... Oksigen 93.96 ...................................
................................ Pasang DC 57.94 Nama Perawat :
Komplikasi ................................... Pasang NGT 96.33
................................... EKG 89.52 Nama Dokter :
................................... Pemeriksaan darah rutin/kimia 90.59
................................... Rontgen dada 87.44
................................... USG Ginjal 88.75
................................... Rehidrasi / Koreksi hipokalemia 99.18 Verifikator :
................................... ...................................
................................... ................................... Tanggal :
................................... ...................................
**
bisa ada atau
tidak
*** wajib ada
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753

tahun kg cm
Diagnosis awal : Gagal Jantung Kode ICD-10 : I50.0 Rencana hari rawat : 7-14 hari
Hari rawat : 1 2 3 4 5 6 7 8 9 10 11
Diagnosis Utama : ............................... ...............................................................................................................................................
Penyerta : ............................... ...............................................................................................................................................
Komplikasi : ............................... ...............................................................................................................................................

Konsultasi :
Bedah K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
Gizi Medik K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
ICU K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V K/V
Darah rutin **
GDS **
Urin rutin **
kolesterol total, Tg **
............................
..................................
................................
Tindakan : Infus ........... : ....... Cc/jam **pasang ** ** ** ** ** ** ** ** ** **
Oksigen ........... l/mnt **
Transfusi PRC **
................................
Obat : antikoagulan/antiplatelet ** ** ** ** ** ** ** ** ** ** **
............................
............................
............................
antihipertensi ............................ ** ** ** ** ** ** ** ** ** ** **
............................
.............................
.............................
.............................
antihiperkolesterolemia
.............................
.............................
.............................
.............................
.............................
.............................
Syok (centang)
.......................... (centang)
Pemulangan :
Meninggal : (kausa)
Varian
Utama Gagal jantung I50.0 Diagnosis fisik 89.03
.................... ... Visite 89.01
Penyerta .................... ... Konsultasi 89.07
.................... ... Transfusi PRC 99.04
.................... ... Infus dan injeksi 99.15/99.22
.................... ... Oksigen 93.96 ...................................

.................... ... EKG 89.52 Nama Dokter :
.................... ... Pemeriksaan DR/kimia 90.59
.................... ... Rontgen dada 87.44
.................... ... USG Ginjal 88.75
.................... ... Verifikator :
99.18
.................... ... Rehidrasi/Koreksi hipokalemia
.................... ... ................................... Tanggal :
.................... ... ...................................
**
bisa ada atau
tidak
*** wajib ada
Tahun :
CP. Gagal Jantung
Nomor Rekam Medis :
4 hari Biaya (Rp)

awat :
hari ...........................
12 13 14
.......................................
.......................................
....................................... tulis komplikasi pada
....................................... kolom hari rawat
...........................
K/V K/V K/V ...........................

K/V K/V K/V ...........................
K/V K/V K/V ...........................
...........................
...........................
...........................
** ** **lepas
...........................
** ** **
** ** **
...........................
Diagnosis Primer
ICD-X
Diagnosis Sekunder
ICD-X
iaya : .....................
nis Tindakan ICD-9 CM
...........................
.........................
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753
tahun kg cm
Diagnosis awal :Artritis Kode ICD-10 : M13.9 Rencana hari rawat : 7 hari
hari
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............
Penyerta : ............................... ............. ............. ............. ............. ............. ............. .............
Komplikasi : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
Bedah K/V K/V K/V K/V K/V K/V K/V
Gizi Medik K/V K/V K/V K/V K/V K/V K/V
ICU/HCU K/V K/V K/V K/V K/V K/V K/V
Darah rutin **
GDS **
Urin rutin **
............................
rontgen tulang lainnya(…………………..) **
..................................
................................
Oksigen ........... l/mnt **
Transfusi PRC **
................................
Obat : anti inflamasi non steroid ** ** ** ** ** ** **
............................
............................
............................
analgesik ............................ ** ** ** ** ** ** **
............................
.............................
.............................
.............................
.............................
Syok (centang)
.......................... (centang)
Pemulangan :
Meninggal : (kausa)
Varian
Utama Artritis M13.9 Diagnosis fisik 89.03
................................... ... Visite 89.01
Penyerta ................................... ... Konsultasi 89.07
................................... ... Transfusi PRC 99.04
................................... ... Infus dan injeksi 99.15/99.22
................................... ... Regulasi cepat insulin 99.17 ........................................
................................... ... Oksigen 93.96 ...................................
................................ ... Pasang DC 57.94 Nama Perawat :
Komplikasi ................................... ... Pasang NGT 96.33
................................... ... EKG 89.52 Nama Dokter :
................................... ... Pemeriksaan darah rutin/kimia 90.59
................................... ... Rontgen dada 87.44
................................... ... USG Ginjal 88.75
................................... ... Rehidrasi / Koreksi hipokalemia 99.18 Verifikator :
................................... ... ...................................
................................... ... ................................... Tanggal :
................................... ... ...................................
**
bisa ada atau
tidak
*** wajib ada
Tahun :
CP.Artritis
Nomor Rekam Medis :
Biaya (Rp)
...........................

kolom hari rawat
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
...........................
Diagnosis Primer
ICD-X
Diagnosis Sekunder
ICD-X
.....................
is Tindakan ICD-9 CM
..........................
........................
:
Activity based cost
Telpon. (0532) 26752 Faximile. (0532) 26753

tahun kg cm
Diagnosis awal : Hipertensi Emergensi Kode ICD-10 : I10 Rencana hari rawat : 5 hari
hari
Hari rawat : 1 2 3 4 5 6
KEGIATAN Hari sakit : ............. ............. ............. ............. ............. .............
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. .............
Penyerta : ............................... ............. ............. ............. ............. ............. .............
Komplikasi : ............................... ............. ............. ............. ............. ............. .............

Konsultasi :
Bedah K/V K/V K/V K/V K/V K/V
Gizi Medik K/V K/V K/V K/V K/V K/V
ICU K/V K/V K/V K/V K/V K/V
Darah rutin **
GDS **
Urin rutin **
............................
..................................
................................
Tindakan : Infus ........... : ....... Cc/jam **pasang ** ** ** **lepas
Untuk komplikasi/penyerta: ** ** ** ** **
Oksigen ........... l/mnt ** ** ** ** **
Kateter urin (psg/lps) ** ** ** ** **
Transfusi PRC ** ** ** ** **
Pasang NGT (psg/lps) ** ** ** ** **
................................
Obat : antihipertensi ** ** ** ** **
............................
............................
............................
............................
............................
.............................
.............................
.............................
.............................
Syok (centang)
.......................... (centang)
Pemulangan :
Meninggal : (kausa)
Varian
Utama hipertensi Emergensi I10 Diagnosis fisik 89.03
..................... ... Visite 89.01
Penyerta ..................... ... Konsultasi 89.07
..................... ... Transfusi PRC 99.04
..................... ... Infus dan injeksi 99.15/99.22
..................... ... Regulasi cepat insulin 99.17 ........................................
..................... ... Oksigen 93.96 ...................................
..................... ... Pasang DC 57.94 Nama Perawat :
Komplikasi ..................... ... Pasang NGT 96.33
..................... ... EKG 89.52 Nama Dokter :
..................... ... Pemeriksaan darah rutin/kimia 90.59
..................... ... Rontgen dada 87.44
..................... ... USG Ginjal 88.75
..................... ... Rehidrasi / Koreksi hipokalemia 99.18 Verifikator :
..................... ... ...................................
..................... ... ................................... Tanggal :
..................... ... ...................................
**
bisa ada atau
tidak
*** wajib ada
Tahun :
CP. HT Emergensi
Nomor Rekam Medis :
wat : 5 hari Biaya (Rp)

Lama rawat :
hari ...........................
7
.............
.............
............. tulis komplikasi pada
............. kolom hari rawat
...........................
K/V ...........................
K/V ...........................
K/V ...........................
...........................
...........................
...........................
...........................
...........................
Diagnosis Primer
ICD-X
Diagnosis Sekunder
ICD-X
Jumlah Biaya : .....................

Jenis Tindakan ICD-9 CM
........................................
...................................
ama Perawat :
ama Dokter :
erifikator :
anggal :
Activity based cost
CLINICAL PATHWAYS & CASEMI
RUMAH SAKIT UMUM DAERAH SUKAM
Alamat : Jalan Tjilik Riwut KM. 5,5 Sukamara Kode Po
Telpon. (0532) 26752 Faximile. (0532) 26753
Nama Pasien : Umur : Berat badan :

tahun kg
Diagnosis awal : Hipertensi Urgensi Kode ICD-10 : I10
Ruang rawat : Kelas : Tarif kamar/hari (Rp) Tanggal masuk :
Hari rawat : 1 2 3
KEGIATAN Hari sakit : ............. ............. .............
Diagnosis Utama : ............................... ............. ............. .............
Penyerta : ............................... ............. ............. .............
Komplikasi : ............................... ............. ............. .............

Konsultasi :
Bedah
......................
ICU
Gizi Medik
Darah rutin **
GDS **
Urin rutin **
............................
..................................
................................
Tindakan : Infus ........... : ....... Cc/jam **pasang
Untuk komplikasi/penyerta: ** ** **
Oksigen ........... l/mnt ** ** **
Kateter urin (psg/lps) ** ** **
Transfusi PRC ** ** **
Pasang NGT (psg/lps) ** ** **
................................
Obat : antihipertensi ** ** **
............................
............................
............................
............................
............................
.............................
.............................
.............................
.............................
Syok (centang)
.......................... (centang)
Pemulangan :
Meninggal : (kausa)
Varian
(penyulit)
Utama hipertensi Urgensi I10 Diagnosis fisik
......................... ... Visite
Penyerta ......................... ... Konsultasi
......................... ... Transfusi PRC
......................... ... Infus dan injeksi
......................... ... Regulasi cepat insulin
......................... ... Oksigen
......................... ... Pasang DC
Komplikasi ......................... ... Pasang NGT
......................... ... EKG
......................... ... Pemeriksaan darah rutin/kimia
......................... ... Rontgen dada
......................... ... USG Ginjal
......................... ... Rehidrasi / Koreksi hipokalemia
......................... ... ...................................
......................... ... ...................................
......................... ... ...................................
Penyakit penyerta / komplikasi yang perlu penanganan lagi, diikuti dengan Clinical Pathway penyakit te
**
bisa ada atau
tidak
*** wajib ada
vity based cost
THWAYS & CASEMIX Tahun :
MUM DAERAH SUKAMARA
t KM. 5,5 Sukamara Kode Pos 74172
6752 Faximile. (0532) 26753 CP. HT Urgensi
Berat badan : Tinggi badan : Nomor Rekam Medis :

kg cm
Rencana hari rawat : 5 hari Biaya (Rp)
Tanggal keluar : Lama rawat :
hari ...........................
4 5 6 7
............. ............. ............. .............
............. ............. ............. .............
............. ............. ............. ............. tulis komplikasi pada
............. ............. ............. ............. kolom hari rawat
...........................
...........................
...........................
...........................
...........................
...........................
...........................
**lepas
** **
** **
** **
** **
** **
...........................
** **
...........................
Diagnosis Primer
ICD-X
Diagnosis Sekunder
ICD-X
Jumlah Biaya : .....................

nis Tindakan ICD-9 CM Jenis Tindakan ICD-9 CM
agnosis fisik 89.03
Visite 89.01
Konsultasi 89.07
ansfusi PRC 99.04
us dan injeksi 99.15/99.22
asi cepat insulin 99.17 ........................................
Oksigen 93.96 ...................................
Pasang DC 57.94 Nama Perawat :
asang NGT 96.33
EKG 89.52 Nama Dokter :
an darah rutin/kimia 90.59
ontgen dada 87.44
USG Ginjal 88.75
/ Koreksi hipokalemia 99.18 Verifikator :
.........................
......................... Tanggal :
.........................
n Clinical Pathway penyakit tersebut
ltasi)
nis Tindakan
Activity based cost
Alamat : Jalan Tjilik Riwut KM. 5,5 Sukamara Kode Pos 74172 CP. DM tipe
Telpon. (0532) 26752 Faximile. (0532) 26753 2+Hipoglikemia
tahun kg cm
Diagnosis awal : DM tipe 2+Hipoglikemia Kode ICD-10 : Rencana hari rawat : 3-5 hari Biaya (Rp)
hari ...........................
Hari rawat : 1 2 3 4 5 6 7
Diagnosis Utama : ............................... ............. ............. ............. ............. ............. ............. .............

Konsultasi :
...........................
Darah rutin **
GDS **
Urin rutin **
............................ ...........................
..................................
................................ ...........................
Tindakan : Infus ........... : ....... Cc/jam **pasang ** ** ** **lepas
Regulasi gula darah ** ** ** ** **

Oksigen ........... l/mnt ** ** ** ** **
Kateter urin (psg/lps) ** ** ** ** **
Transfusi PRC ** ** ** ** **
Pasang NGT (psg/lps) ** ** ** ** **
................................ ...........................
Obat : D40% sc. ** ** **
............................
............................
............................
............................
............................
.............................
.............................
............................. ...........................
Syok (centang)
Pemulangan : ICD-X
Meninggal : (kausa)
Varian
Utama DM tipe 2+hipoglikemia ... Diagnosis fisik 89.03
.............................. ... Visite 89.01
Penyerta .............................. ... Konsultasi 89.07
.............................. ... Transfusi PRC 99.04
.............................. ... Infus dan injeksi 99.15/99.22
.............................. ... Regulasi cepat insulin 99.17 ........................................
.............................. ... Oksigen 93.96 ...................................
.............................. ... Pasang DC 57.94 Nama Perawat :
Komplikasi .............................. ... Pasang NGT 96.33
.............................. ... EKG 89.52 Nama Dokter :
.............................. ... Pemeriksaan darah rutin/kimia 90.59
.............................. ... Rontgen dada 87.44
.............................. ... USG Ginjal 88.75
.............................. ... Rehidrasi / Koreksi hipokalemia 99.18 Verifikator :
.............................. ... ...................................
.............................. ... ................................... Tanggal :
.............................. ... ...................................
**
bisa ada
atau tidak
*** wajib ada
Tahun :
CP. DM tipe
2+Hipoglikemia
r Rekam Medis :
Biaya (Rp)
...........................

kolom hari rawat
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Diagnosis Primer
ICD-X
Diagnosis Sekunder
ICD-X
.....................
ICD-9 CM

Clinical Pathways

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Clinical Pathways

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Activity based cost

CLINICAL PATHWAYS & CASEMIX Tahun :

Penegakan Diagnosis Visite DU/Sp ...........................

Oksigen ........... l/mnt ** ** ** ** ** **

Nama Pasien : Umur : Berat badan : Tinggi badan :

Penegakan Diagnosis Visite DU/Sp

Nama Pasien : Umur : Berat badan : Tinggi badan :

Penegakan Diagnosis Visite DU/Sp ...........................

CP: asfiksia neonatorum

Nama Pasien : Umur : Berat badan : Tinggi badan :

Penegakan Diagnosis Visite DU/Sp ...........................

CP: asfiksia neonatorum

Nama Pasien : Umur : Berat badan : Tinggi badan :

Penegakan Diagnosis Visite DU/Sp ...........................

Nama Pasien : Umur : Berat badan : Tinggi badan :

Penegakan Diagnosis Visite DU/Sp ...........................

Nama Pasien : Umur : Berat badan : Tinggi badan :

Penegakan Diagnosis Visite DU/Sp ...........................

Nama Pasien : Umur : Berat badan : Tinggi badan :

Penegakan Diagnosis Visite DU/Sp ...........................

feses lengkap (centang) ***

Tindakan : pasang/lepas infus (centang) ***pasang ***lepas

O2 NK 1-3 lpm (centang) **

antibiotik (selektif): (centang) ** ** ** ** ** ** **

antiamoeba: (centang) ** ** ** ** ** ** ** ...........................

Nama Pasien : Umur : Berat badan : Tinggi badan :

Penegakan Diagnosis Visite DU/Sp ...........................

GDS (centang) ***

feses lengkap (centang) **

urin lengkap (centang) **

Tindakan : pasang/lepas infus (centang) ***pasang ***lepas

O2 NK 1-3 lpm (centang) **

diazepam iv 0,2-0,5 mg/kgBB iv (centang) ** ** ** ** **

inj phenobarbital 30 mg/50 mg/75 IM (loading dose) (centang) ***

inj parasetamol 10-15 mg/KgBB iv (centang) ** ** ** ** ** ...........................

po diazepam 0,3-0,5 mg/KgBB (centang) *** ** ** ** **

CP: Kejang Demam

Nama Pasien : Umur : Berat badan : Tinggi badan :

Penegakan Diagnosis Visite DU/Sp

feses lengkap (centang) **

O2 NK 1-3 lpm (centang) **

CP: Demam Tifoid

Nama Pasien : Umur : Berat badan : Tinggi badan :

Penegakan Diagnosis Visite DU/Sp

O2 NK 1-3 lpm (centang) **

Obat : inj amoksisilin 150-200 mg/hari (centang) ** ** **

inj cefotaxime……… (centang) ** ** **

po azitromisin 10 mg/kgBB/hari (centang) ** ** **

CP: Faringitis Akut

Nama Pasien : Umur : Berat badan : Tinggi badan :

Penegakan Diagnosis Visite DU/Sp

O2 NK 1-3 lpm (centang) **

Obat : inj ampisilin sulbaktam 100 mg/kg/hari (centang) ** ** ** ** **

inj cefotaxime 50-100 mg/kgBB/hari (centang) ** ** ** ** **

inj ceftriaxone 50-100 mg/kgBB/hari (centang) ** ** ** ** **

CP: Bronkitis Akut

Nama Pasien : Umur : Berat badan : Tinggi badan :

Penegakan Diagnosis Visite DU/Sp ...........................

urin rutin (centang) ***

O2 NK 1-3 lpm (centang) **

Obat : inj gentamisin 5 mg/kgBB (centang) ** ** ** ** ** ** **

inj cefotaxime 50-100 mg/kgBB/hari (centang) ** ** ** ** ** ** **

CP: ISK (anak)

Oksigen ........... l/mnt

Tindakan : pasang/lepas infus (centang) pasang lepas

antibiotik (selektif): (centang) **

antiamoeba: (centang) ** ...........................

Tindakan : pasang/lepas infus (centang) pasang lepas

diazepam iv 0,2-0,5 mg/kgBB iv (centang) **

inj parasetamol 10-15 mg/KgBB iv (centang) ** ...........................

po diazepam 0,3-0,5 mg/KgBB (centang) * **

Obat : inj amoksisilin 150-200 mg/hari (centang) **

inj cefotaxime……… (centang) **

po azitromisin 10 mg/kgBB/hari (centang) **

Obat : inj ampisilin sulbaktam 100 mg/kg/hari (centang) **

inj cefotaxime 50-100 mg/kgBB/hari (centang) **

inj ceftriaxone 50-100 mg/kgBB/hari (centang) **

Obat : inj gentamisin 5 mg/kgBB (centang) **

inj cefotaxime 50-100 mg/kgBB/hari (centang) **

Tindakan : pasang/lepas infus (centang) pasang lepas

diazepam iv 0,2-0,5 mg/kgBB iv (centang) **

inj parasetamol 10-15 mg/KgBB iv (centang) **

inj ceftriaxone 80-100 mg/KgBB/Hari (centang) **

po.phenobabital 3-5 mg/Kg BB/hari (centang) **

po asam valproat 15-40 mg/KgBB/hari dlm 2-3 dosis (centang) **

po Asam Mefenamat 3x500 mg **

po Asam Mefenamat 3x500 mg (centang) **

Progesteron natural 200-400 mcg/hari pervaginam (centang) **

po Asam tranexamat 3x500 mg iv (centang) **

inj ranitidine 50 mg/12 jam iv (centang) **

DJJ * * * * * **

po Metil dopa 3x250-500 mg (centang) **

po Nifedipin 4x10 mg (centang) **

inj dexametason 1 amp/12 jm (centang) **

po Metil dopa 3x250-500 mg (centang) **

inj dexametason 1 amp/12 jm (centang) **

Sectio cesaria *

po Nifedipin 10-20 mg (centang) **

inj dexametason 1 amp/12 jm (centang) **

po amoksilin 3x500 mg (centang) **

po asam mefenamat 3x500 mg (centang)