* Penyakit Penyerta 23
* Komplikasi 24
Administrasi RM lengkap 10,000
Akomodasi Sewa kamar Sewa kamar Sewa kamar 3x30000 90,000
Akomodasi lain Akomodasi lai Akomodasi lain Akomodasi lain
Assesmen Klinis :
* Pemeriksaan dokter 25 dr. Sp. OG dr. Sp. OG dr. Sp. OG 3x30000 90,000
* Konsultasi 26 dr. SpA dr. SpA 2x10000 20,000
Pemeriksaan Penunjang27
Laborat Darah rutin 40,000
Gol Darah 8,500
Radiologi
Tindakan : 28
Hasil (Outcome): 31
*
*
*
Pendidikan/Rencana 32
Pemulangan :
Varians : 33
halaman 2
FORMAT UMUM CLINICAL PATHWAYS
Halaman 2
FORMAT UMUM CLINICAL PATHWAYS
Hasil (Outcome): 31
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
Pendidikan/Rencana 32 ................... ............................. .......................... ........................ ..........................
Pemulangan :
Varians : 33
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
halaman 1
FORMAT UMUM CLINICAL PATHWAYS
Pemeriksaan Penunjang27
Laborat Darah Rutin
GDS
CT BT
Radiologi
Tindakan : 28
* Dokter ECG
Hasil (Outcome): 31
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
Pendidikan/Rencana 32 ................... ............................. .......................... ........................ ..........................
Pemulangan :
Varians : 33
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
Jumlah Biaya
Nama Perawat : 36 Diagnosis Akhir 34 Kode ICD 10 Jenis Tindakan 35 Kode ICD 9 - CM
.............................. * Utama ............................. J.35.0 * Kode INA DRG : O31.151
Nama Dokter : 37 * Penyerta ............................. ............................. *
...................... ............................. ............................. *
Nama Pelaksana * Komplikasi ............................. ............................. *
Verifikasi : 38 ............................. ............................. *
......................
T UMUM CLINICAL PATHWAYS
Biaya (Rp) :
.....20.......
60,000
60,000
60,000
1,022,476
Halaman 2
FORMAT UMUM CLINICAL PATHWAYS
* Dokter
di IBS ECG EKEK IOL, Trabelculectomi
Anesthesi ECG
* Keperawatan Vitalsign
Rekam ECG Vitalsign Vitalsign Vitalsign Vitalsign Askep
Pasang Infus Observasi Observasi Observasi Sederhana
Secrent Injeksi Injeksi Injeksi Kecil
Pengawasan Infus Pengawasan Infus Pengawasan Infus Pengawasan Infus EKG
Redresing Rawat Luka Rawat Luka Rawat Luka
Ambulansi
Obat-obatan : 29
* Obat
Obat IBS BSS 250 ml
Provis 0,5
Benang Nylon 10-01/2
Injeksi Markain 1/5 amp
Inj. Xylocain 1/5 amp
Trypan blue 1/5
Silve Knife 1/5
Lensa taman 1
Bovie Aaron 1/5
* Obat Anestesi Diprivan 1 amp 132293
Inj. Sedacum 2 amp 2337
Pethidine 1 amp 164295
Dexamethason 2 am 1603
SA 1 AMP 3176
Ephedrin 1 amp 15125
Aminophylin 1 amp 68885
Nokoba 1/10 amp 8250
Dextrose 5 % 100 cc 10209
Infus RL 1 kolf 6500
O2 150 L
*Obat Ruangan Diamox tab 3x1 Inj. Gentamycin 1 amp Diamox tab 3x1 Diamox tab 3x1 Diamox tab 3x1
Infus RL 3 kolf Inj. Dexamethason 1 a Sefadroxil cap 500 mg Sefadroxil cap 500 Sefadroxil cap 500 mg 3x1
C. Mydriatil TM 1/3 btl As Met tab 500 mgAs Met tab 500 As Met tab 500 mg 3x1
Methil prednisolon Methil prednisol Methil prednisolon 8 mg tab 3x1
C. Xytrol SM 1 tab
* Obat pulang Diamox tab 3x1= 9
Sefadroxil cap 500 mg 3x1= 8
As Met tab 500 mg 3x1 = 7
Methil prednisolon 8 mg tab 3x1= 7
AT UMUM CLINICAL PATHWAYS
Biaya (Rp) :
.....20.......
31,000
150,000
150,000
25,000
25,000
10,000
40,000
17,000
17,000
5000
17000
17000
-
55,000
1,200,000
25,000
480,000
100,000
24,000
210,000
25,000
223,902
81,592
FORMAT UMUM CLINICAL PATHWAYS
Balance cairan
Obat Pulang
Vit.B Compleks = 10
Vit.C = 10 151,846
BHP
ALKES
Nutrisi : 29
Diet Lunak Diet Lunak Diet Lunak Diet Lunak 30,000
Mobilisasi : 30
Hasil (Outcome): 31
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
Pendidikan/Rencana 32 ................... ............................. .......................... ........................ ..........................
Pemulangan :
Varians : 33
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
Jumlah Biaya 851,846
Nama Perawat : 36 Diagnosis Akhir 34 Kode ICD 10 Jenis Tindakan 35 Kode ICD 9 - CM
.............................. * Utama ......................... A.91 * Kode INA DRG : 184122
Nama Dokter : 37 * Penyerta ............................. ............................. *
...................... ............................. ............................. *
Nama Pelaksana * Komplikasi ............................. ............................. *
Verifikasi : 38 ............................. ............................. *
......................
halaman 1
FORMAT UMUM CLINICAL PATHWAYS
Pemeriksaan Penunjang27
Laborat Darah rutin GDS GDS GDS GDS 45,000
BTA 50,000
GDS
Radiologi -
Tindakan : 28
* Dokter -
* Keperawatan Kompres, Ganti Bal Kompres, Ganti Balut Kompres, Ganti Balut Kompres, Ganti Balut Kompres, Ganti Balut 140,000
Infus, Injeksi Infus, Injeksi Infus, Injeksi Infus, Injeksi Infus, Injeksi Infus, Injeksi 32,000
Redressing Redressing Redressing 420,000
Observasi tanda vitaObservasi tanda vital Observasi tanda vital Observasi tanda vital Observasi tanda vital Observasi tanda vital
Oral Hygiene Oral Hygiene Oral Hygiene Oral Hygiene Oral Hygiene Oral Hygiene
Pengawasan Infus Pengawasan Infus Pengawasan Infus Pengawasan Infus Pengawasan Infus Pengawasan Infus
Memandikan Memandikan Memandikan Memandikan Memandikan
Observasi Pasien Observasi Pasien Observasi Pasien Observasi Pasien Observasi Pasien Observasi Pasien
Obat-obatan : 29 97500 Inf D5 & RL 3kolf Inf D5 & RL 3kolf Inf D5 & RL 3kolf Inf D5 & RL 3kolf Inf D5 & RL 3kolf
148500 Inj.Amoxicilin 3x1gr Inj.Amoxicilin 3x1gr Inj.Amoxicilin 3x1gr Inj.Amoxicilin 3x1gr Inj.Amoxicilin 3x1gr Inj.Amoxicilin 3x1gr
1728 Tab.Prednison 3x2 Tab.Prednison 3x2 Tab.Prednison 3x2 Tab.Prednison 3x2 Tab.Prednison 3x2 Tab.Prednison 3x2
13266 Tab.Interhistin 3x1 Tab.Interhistin 3x1 Tab.Interhistin 3x1 Tab.Interhistin 3x1 Tab.Interhistin 3x1 Tab.Interhistin 3x1
57750 Salep Betason N= 1 Salep Betason N= 1 Salep Betason N= 1 Salep Betason N= 1 Salep Betason N= 1 Salep Betason N= 1
6546 Ofloxacin 400mg x Ofloxacin 400mg x 1 Ofloxacin 400mg x 1 Ofloxacin 400mg x 1 Ofloxacin 400mg x 1 Ofloxacin 400mg x 1
4849 Acyclovir 5x800mg Acyclovir 5x800mg Acyclovir 5x800mg Acyclovir 5x800mg Acyclovir 5x800mg Acyclovir 5x800mg
3960 Asmef 3x500mg Asmef 3x500mg Asmef 3x500mg Asmef 3x500mg Asmef 3x500mg Asmef 3x500mg 411,359
BHP Rivanol 500cc Rivanol 500cc Rivanol 500cc Rivanol 500cc Rivanol 500cc Rivanol 500cc 759,189
Betadine 60cc Betadine 60cc Betadine 60cc Betadine 60cc Betadine 60cc Betadine 60cc
Kassa 1/4 rol Kassa 1/4 rol Kassa 1/4 rol Kassa 1/4 rol Kassa 1/4 rol Kassa 1/4 rol
Plester 1/2 rol Plester 1/2 rol Plester 1/2 rol Plester 1/2 rol Plester 1/2 rol Plester 1/2 rol
Perban 5cm=5 rol Perban 5cm=5 rol Perban 5cm=5 rol Perban 5cm=5 rol Perban 5cm=5 rol Perban 5cm=5 rol
Kapas 5gr Kapas 5gr Kapas 5gr Kapas 5gr Kapas 5gr Kapas 5gr
Alkohol 96%=5cc Alkohol 96%=5cc Alkohol 96%=5cc Alkohol 96%=5cc Alkohol 96%=5cc Alkohol 96%=5cc
handschoon = 4 handschoon = 4 handschoon = 4 handschoon = 4 handschoon = 4 handschoon = 4
ALKES Abocat = 1 Abocat = 1 Abocat = 1 115,509
Infus set = 1 Infus set = 1 Infus set = 1
Spuit 5cc = 4 Spuit 5cc = 4 Spuit 5cc = 4 Spuit 5cc = 4 Spuit 5cc = 4
Spuit 3cc = 1 Spuit 3cc = 1 Spuit 3cc = 1 Spuit 3cc = 1 Spuit 3cc = 1
Nutrisi : 29
TKTP TKTP TKTP TKTP TKTP 6X55.000 330,000
Mobilisasi : 30
Mobilisasi Mobilisasi Mobilisasi Mobilisasi Mobilisasi Mobilisasi
Hasil (Outcome): 31
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
Pendidikan/Rencana 32 ................... ............................. .......................... ........................ ..........................
Pemulangan :
Varians : 33
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
Jumlah Biaya 2,724,057
Nama Perawat : 36 Diagnosis Akhir 34 Kode ICD 10 Jenis Tindakan 35 Kode ICD 9 - CM
* Utama ............................. A30.4,A30.9,L30. * Kode INA DRG : O94101
.............................. B01.9, B02.9
Nama Dokter : 37 * Penyerta ............................. ............................ *
...................... ............................. ............................ *
Nama Pelaksana * Komplikasi ............................. ............................ *
Verifikasi : 38 ............................. ............................ *
......................
halaman 1
FORMAT UMUM CLINICAL PATHWAYS
inj meropenem 2x100 mg inj meropenem 2x100 inj meropenem 2x100 inj meropenem 2x 10 inj meropenem 2x 10 inj meropenem 2x 100 mg
Radiologi
Tindakan : 28
* Dokter
* Keperawatan 140,000
450,000
*Fisioterapi
Obat-obatan : 29 Infus 41 = 4kolf 47,024
Hasil (Outcome): 31
* ................... ............................ .......................... ........................ ..........................
* ................... ............................ .......................... ........................ ..........................
* ................... ............................ .......................... ........................ ..........................
Pendidikan/Rencana 32 ................... ............................ .......................... ........................ ..........................
Pemulangan :
Varians : 33
................... ............................ .......................... ........................ ..........................
................... ............................ .......................... ........................ ..........................
................... ............................ .......................... ........................ ..........................
halaman 2