CLINICAL_PATHWAY

FORMAT UMUM CLINICAL PATHWAYS
LOGO CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

1 SMF BEDAH UMUM RSUD RAA SOEWONDO PATI 3
CLAVUS/ATHEROMA/LIPOMA/PAPILOMA/NEVUS/NEUROFIBROMA/ABSCESS/ 4
NAEGLE EXTRAKSI/KELOID Ǿ < 2cm/DAWIR/TINDIK/CIRCUMSISI/CATETERISASI
Tahun 2012 5
Nama Pasien : 6 Umur : 7 Berat Badan : 8 Tinggi Badan : 9 Nomor Rekam Medis : 10
.................................... ............ .........kg ............cm ..........................
Diagnosis Awal................................11 Kode ICD 10........................12 Rencana rawat.............hari 13
R. Rawat Tgl/Jam masuk : Tgl/Jam keluar : Lama rawat : Kelas : Tarif/hr (Rp) : Biaya (Rp) :
.....14....... .....15....... .....16....... .....17.........hari .....18....... .....19....... .....20.......
Aktivitas Pelayanan
Hari Rawat 1 Hari Rawat 2 21 Hari Rawat 3 Hari Rawat 4 Hari Rawat 5
Hari Sakit:... Hari Sakit:... Hari Sakit:... Hari Sakit:... Hari Sakit:...
Diagnosis :
* Penyakit Utama 22 ................... ............................. .......................... ........................ .......................... ...................
* Penyakit Penyerta 23 ................... ............................. .......................... ........................ .......................... ...................
* Komplikasi 24 ................... ............................. .......................... ........................ .......................... ...................
Administrasi RM Lengkap ............................. .......................... ........................ .......................... 25.000 + 6.000 31,000
Akomodasi ................... ............................. .......................... ........................ .......................... ................... -
................... ............................. .......................... ........................ .......................... ................... -
Assesmen Klinis :
* Pemeriksaan dokter 25 dr.Sp.B ............................. .......................... ........................ .......................... ................... 25,000
* Konsultasi 26 ................... ............................. .......................... ........................ .......................... .......................... -
Pemeriksaan Penunjang27 ................... ............................. .......................... ........................ .......................... .......................... ........................
Laborat Darah rutin ............................. .......................... ........................ .......................... .......................... 45,000
Radiologi ................... -
Tindakan : 28 ................... ............................. .......................... ........................ .......................... .......................... ..........................
* Dokter Excisi 125,000
* Keperawatan Perawatan Luka ............................. .......................... ........................ .......................... ..........................
Vitalsign ............................. .......................... ........................ .......................... ..........................
Obat-obatan : 29 Amoxicilin 3x500mg=15tab ............................. .......................... ........................ .......................... ..........................
Asmef 3x500mg =15tab ............................. .......................... ........................ .......................... .......................... 8,750
BHP Kassa 10lbr
Alkohol70 =50cc
Betadine 50cc 11,175
ALKES Handschoon 2 psg 16900
Besturi 1 buah 5294
Benang cromix 2.0 = 1/2 6700
mtr Benang Zide 75cm 4650
Jarum jahit 1 buah 1375 34,925
Nutrisi : 29 ................... ............................. .......................... ........................ .......................... .......................... ..........................
Mobilisasi : 30
Hasil (Outcome): 31
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
Pendidikan/Rencana 32 ................... ............................. .......................... ........................ ..........................
Pemulangan :
Varians : 33
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
Jumlah Biaya 280,850

Nama Perawat : Diagnosis Akhir 34 Kode ICD 10 Jenis Tindakan 35 Kode ICD 9 - CM
............................ * Utama ............................. K40.9,K41.9 * Kode INA DRG : O61.141
Nama Dokter : 37 * Penyerta ............................. ............................. *
...................... ............................. ............................. *
Nama Pelaksana * Komplikasi ............................. ............................. *
Verifikasi : 38 ............................. ............................. *
......................

CLINICAL_PATHWAY

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CLINICAL_PATHWAY

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FORMAT UMUM CLINICAL PATHWAYS

LOGO CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

Jumlah Biaya 280,850

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