Formulir Unit Rawat Inap

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1/59

REKAM MEDIS INSTALASI RAWAT INAPRUMAH SAKIT ‘AISYIYAH

“SITI FATIMAH”PIMPINAN DAERAH ‘ASIYIYAH SIDOARJO

Jl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o RM)

RIN KASAN MASUK KELUAR `

Nama Pasien : Nama Keluarga : Umur : Kelamin: Lk. Pr.

Ruang :Kls :

Alamat lengkap dan no.Telp

RT :RW :

Desa : Kecamatan/Ka upaten :

Tgl.La!ir :

Tempat La!ir :

"angsa : Agama : No. KTP / ket. Lain :

Peker#aan $klien / suami/A%a!&: Alamat Lengkap Peker#aan : Telepon :

Penanggung Pem a%aran : Alamat Penanggung : Telepon :

Keluarga %angTerdekat Alamat pem erita!uan %ang Terdekat : Telepon :

Nama Pengirim / 'nstansi : Alamat Lengkap Pengirim : Telepon :

Tgl. (asuk :)am :

Tgl. Keluar :)am :

Tgl. (eninggal : )am :

Nama Petugas %ang (enerima : Tanda Tangan:

*ara (asuk $ )alan/ Kursi Roda / "rangkat &Dira+at %ang ke : Tgl. Ak!ir Dira+at :

Diagnosa (asuk :

Dira+at di Ruang / kelas : Laman%a :Pinda! ke Ruang / kelas : Laman%a :Diru#uk ke :D'A,N- A UTA(A K-D '*D

"A" K * LAKAAN / K RA*UNAN K-D '*D

K-(PL'KA ' K-D '*D

D'A,N- A KUND R K-D '*D

D'A,N- A PA K-D '*D

-P RA ' K-D '*D

-T-P ' K-D '*D

AL R,' K-D '*D

K ADAAN K LUAR *ARA K LUAR :0. em u! 1. (eninggal 2 13 #am 0. Atas Persetu#uan 1. elesai - ser4asi 0

0. 5. Per aikan 6. (eninggal 7 13 #am 5. Pulang Paksa 6. Lain8lain9. "elum em u! . *acat 9. Diru#uk

;. Lain8lainDokter %ang mera+at

$.......................................&

No. Rekam (edis

/ /


2/59

Nama Terang

REKAM MEDIS INSTALASI RAWAT INAP RUMAH SAKIT ‘AISYIYAH

“SITI FATIMAH” PIMPINAN DAERAH ‘ASIYIYAH SIDOARJO

Jl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o

RM)/.A

LEM0AR UNTUK MENEMPEL SURAT1MRS%RUJUKAN DLL2

Nama Lengkap : ....................................... .......................... ..... Umur : ............................ ............................ .....Ruangan : ..................................................................... Kelas : ............................................................

05000<=3;

6195

PENEMPELAN PERTAMA 0

No. Rekam (edis

/ /


3/59


4/59


“SITI FATIMAH” LA0EL TRIA E PIMPINAN DAERAH ‘ASIYIYAH SIDOARJO


R(80

STATUS PASIENU D

NA(A : .......................... .......................... ....................) N' K LA('N: L / P U(UR : ............................>R/"LN/T>

ALA(AT : ........................................................................ ................................................................................................................................................ ........................................................................ T,L./)A( : ............................/ .................W'"

........................................................................ $kedatangan&........................................................................

T" /"" : ....................*(/ ...................K, ,-L-N,AN DARA> : ........................Ri+a%at Pen%akit Da!ulu $RPD& : ....................................................... AL R,' : .........................

T,L. )A( : ........................ ../....................W'"$ penanganan&

U"B KT'? :AC/ >C :

-"B KT'? :K ADAAN U(U( :T : ............../............. ...mm>g N : ................. /menit RR : ...................... /menit t : ................. E*Anemis : F / 8 'cterus : F / 8 *%anosis : F / 8 D%spnoe : F / 8P ( R'K AAN ?' 'K :

K PALA / L > R :

T>-RA :

A"D-( N :

TR ('TA :

TA(PAK D PAN TA(PAK " LAKAN,

No. Rekam (edis

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5/59

R(80PEMERIKSAAN PENUNJAN MEDIS 1LA0% RO4% EK % DLL2

A ( NT :D K R)A : D "AND'N, :

PLANN'N, :P NATALAK ANAAN :

T'NDAK LAN)UT : P PULAN, P (R P ( N-LAK (R P ( N'N,,AL

P D'RU)UK DLLD-KT R )A,A U,D

idoar#o@ ...........................................

$ .......................................................&


6/59

RUMAH SAKIT ‘AISYIYAH



R(80 "

PEN KAJIAN Na5a Pa6*en 7 No. RM.U D 8 POLIPengka#ian diam il dari : Pasien -rang lain Nama : ....................... ............................ . >u ungan : ........................ ............................Ri+a%at Kepera+atan :0. Kelu!an Utama : ........................ .......................... ............................ .......................... ......................5. Kelu!an Pen%akit ekarang : ......................... ............................ .......................... .......................... .....................

............................................................................................................................. .............................................................................................................................

9. Ri+a%at Pen%akit Da!ulu : Tidak ada

Ada Kapan :Dimana :

Dengan Pen%akit :1. Ri+a%at Pen%akit Keluarga : D( T!%p!oid ......................... ...................

T"* P)K >%pertensi >epatitis

6. Ri+a%at Alergi : Tidak ada Ada ........................ ............................ ..........................

. Ri+a%at Tum u! Kem ang $k!usus untuk pasien anak& : Normal Tidak Normal : .......................... .......................... .......................... ...........;. Ri+a%at 'munisasi

Lengkap Tidak Lengkap : ........................ .......................... ............................ ...........3. Pemeriksaan Umum

"0 : RR : ......................... . / mnt pontan Teratur $ reat!ing & Tidak pntan Tidak Teratur

u!u : ...... E* W!eGing Ada Tidak Ada Ronc!i Ada Tidak Ada Tarikan 'ntercostac Ada Tidak Ada Perna asan cuping !idung Ada Tidak Ada P-5 : ........................ ..............

"5 TD : ......................mm>g Pulse : ................ / mnt *RT : 085 dtk $"lood& (AP : ..................... ............ Per usi : .......................... ..... H 9 dtk Pendara!an : Ada .........................** Tidak *%anosis : Ba Tidak

"9 *, : .......................... .....$ "rain& Kesadaran : *ompos (entis Re leksi *a!a%a : Positi Negati Apatis Pupil : 'sokor Anisokor omnolent Kelumpu!an : Tidak oporus *oma Ada : ........................ ......

"1 $ "lander& "AK : pontan Tidak pontan Produksi Urine : ..........................**"6 "A" Normal "ising usus : ......................... / mnt

$ "o+el & *air (ual ......................... .... (unta! " Dislokasi Tidak Ada ?aktur : Tidak Ada

Ada : ....................... .................. Ada : ......................... ............Pemeriksaan Penun#ang : La oratorium : .......................... ..... Radiologi : ......................... ...... P RAWAT P N,KA)' : *, : ....................... ....... Tanda Tangan :Diagnosa (edis : .......................... ............................ ...Terapi (edis I ....................... .......................... ........ Nama Terang : ......................... .............

Keterangan : Centang (√) sesuai pilihan dan untuk titik-titik (....) : tulis sesuai keadaan pasien

9 9


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“SITI FATIMAH” PIMPINAN DAERAH ‘ASIYIYAH SIDOARJOJl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o

RM )!No. Re:a5 Me+*6

9 9

3ATATAN PEMERIKSAAN FISIK Nama Lengkap :............................. .......................... ............... Umur : ......................... ............................ .............Ruangan : ..................................................................... Kelas : .................................................................

'. ANA(N 'A. Kelu!an Utama :

................................................................................

................................................................................

................................................................................

................................................................................*. Ri+a%at Pen%akit ekarang :

................................................................................

................................................................................

................................................................................

................................................................................

". Ri+a%at Pen%akit Keluarga : ................................................................................. .................................................................................. .................................................................................. ..................................................................................

*. Ri+a%at Pen%akit Da!ulu : ................................................................................. .................................................................................. .................................................................................. ..................................................................................

'' . P ( R'K AAN ?' 'K A. Tanda Jital

,* : ....................... .......................... ..............Tensi : ........................ ..........................mm/>g

Nadi : ....................... ............................C/mntu!u : ....................... .......................... ... E*

RR : ....................... .......................... ...C/mnt"" : ....................... .......................... ..Kg

". tatus general dan lokalis ................................................................................. .................................................................................. ..................................................................................

.................................................................................. ..................................................................................

..................................................................................'''. P ( R'K AAN P NUN)AN,

A. Permintaan pemeriksaan la oratorium: ........................................................................................................................................................................: .......................................................................................................................................................................

". Permintaan pemeriksaanRadio Diagnostik : ........................................................................................................................................................................: .......................................................................................................................................................................

'J. D'A,N- A AWAL0& ........................................................................................................ '*D : ......................................................5& ........................................................................................................ '*D : ......................................................9& ........................................................................................................ '*D : ......................................................J. T RAP' " LU( (R $RAWAT )ALAN&

........................................................................................................................................................................ .

.......................................................................................................................................................................

........................................................................................................................................................................

J'. T RAP' / T'NDAKAN AWAL........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

idoar#o@ ........................ .......................... ......................


8/59

$ ......................... .......................... ............................ ...& Tanda Tangan dan Nama Terang



Jl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o RM)#.A

INSTRUKSI DOKTER

Nama Lengkap : .......................... .......................... ........ Umur : .......................... .......................... ...................Ruangan : ............................................................ Kelas : ......................................................................

Tanggal

Per!atian : untuk semua #enis instruksi %ang di erikan ole! dokter@misaln%amengenai per#alanan pen%akit@ pem erian o at@ diit@ pera+atank!usus@ in us@ 8Ra%@ la oratorium. )angan lupa tanggal@ pukul@tanda tangan dan nama terang #uga dicantumkan

Para

P R)ALANAN P NBAK'T P N,-"ATAN / 'N TRUK '

No. Rekam (edis

/ /


9/59


10/59


11/59



Jl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o RM)#.3

INJEKSI NA(A : ............................. ............... D : ......................... ................................. ......ALA(AT : ............................................. D-KT R : ................................................................

............................................. RUAN, : ................................................................U(UR : . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .) N' K LA('N: L / P

'N) K '

T,L : ............................................................. T,L : .............................................................

PA,' -R (ALA( PA,' -R (ALA()A( PR? K T )A( PR? K T )A( PR? K T )A( PR? K T )A( PR? K T )A( PR? K T

'N) K 'T,L : ............................................................. T,L : .............................................................



12/59



Jl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o RM)&3

ORAL NA(A : ............................. ............... D : ......................... ................................. ......ALA(AT : ............................................. D-KT R : ................................................................

............................................. RUAN, : ................................................................U(UR : . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .) N' K LA('N: L / P

-RALT,L : ............................................................. T,L : .............................................................

PA,' -R (ALA( PA,' -R (ALA(

)A( PR? K T )A( PR? K T )A( PR? K T )A( PR? K T )A( PR? K T )A( PR? K T

-RALT,L : ............................................................. T,L : .............................................................



13/59

REKAM MEDIS INSTALASI RAWAT INAP RUMAH SAKIT ‘AISYIYAH RM)&

“SITI FATIMAH”PIMPINAN DAERAH ‘ASIYIYAH SIDOARJO


ASUHAN KEPERAWATAN 8 KE0IDANAN

Tgl)am !i t

Diagnosa PerencanaanTindakan kepera+atan / ke idanan 4aluasi TT

Kepera+atan / Ke id Tu#uan K> 'nter4ensi

NamaLengkap : ....................................Umur : ....................................Ruangan /


14/59

ASUHAN KEPERAWATAN 8 KE0IDANAN


15/59


16/59



Jl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o RM)"

3ATATAN O0AT 8 ALKES

Nama Lengkap : .......................... .......................... ........... Umur : ......................... ............................ .......................... ......Ruangan : .............................................................. Kelas : .....................................................................................

N-. NA(A -"AT/ALKTAN,,AL K ("AL'

K T RAN,ANT,L )(L TTDK LUAR,A

TTDP TU,A

Kepala Ruangan

.......................... Nama Terang

No. Rekam (edis

/ /


17/59


“SITI FATIMAH”Jl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o RM);

PENEMPELAN SALINAN RESEP

Nama Lengkap : .......................... ............................ ........... Umur : ........................ ............................ ...............Ruangan : ................................................................ Kelas : ...................................................................

Tempelkan disini

Tempelkan disini

Tempelkan disini

REKAM MEDIS INSTALASI RAWAT INAP


No. Rekam (edis / /


18/59



RM) $

UNTUK PENEMPELANHASIL PEMERIKSAAN LA0ORATORIUM

Nama Lengkap : .......................... ............................ .. Umur : .......................... .......................... ...............Ruangan : ....................................................... Kelas : ...................................................................

05000<=3;

61950PENEMPELAN PERTAMA

REKAM MEDIS INSTALASI RAWAT INAP


No. Rekam (edis

/ /


19/59


Jl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o RM)

HASIL PEMERIKSAAN US % RONT EN%E3

Nama Lengkap : .......................... .......................... ............. Umur : ............................ .......................... .............Ruangan : ................................................................ Kelas : ...................................................................

US yang +*5*n


20/59



Jl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o RM) /

0ALAN3E 3AIRAN /! JAM Nama Lengkap : ............................ .......................... ........... Umur : ........................... .......................... ...Ruangan : ................................................................ Kelas : .........................................................

TAN AL JAM N A D I

S U H U

TENSI RR INPUT OUTPUT

K T

INFUS TRANFUSI MINUM URINE DRAIN M.S

JUMLAH 7

No. Rekam (edis

/ /


21/59


“SITI FATIMAH” PIMPINAN DAERAH ‘ASIYIYAH SIDOARJO Jl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o RM) #

PERSETUJUAN PASIEN RAWAT INAP No. Re:a5 Me+*6 7 ...............Bang ertanda tangan di a+a! ini :

P NAN,,UN, )AWA" / PA ' N &

Nama : ....................................................................................................................

No. KTP / '( : ....................................................................................................................

Alamat : ....................................................................................................................

Peker#aan : ....................................................................................................................

Dengan ini men%atakan dengan sesunggu!n%a a!+a sa%a setu#u untuk dilakukan ra+at

inap di kamar .............. Dan sanggup mem a%ar ia%a %ang tim ul selama pera+atan

ter!adap diri sa%a/suami/istri/anak/orang tua/saudara & sa%a : dengan nama

.............................................................. $L/P& umur : .................................................

idoar#o@ .........................................

Petugas Ruma! akit : Bang (en%atakan :

Tanda tangan dan nama terang Tanda tangan dan nama terang

*ATATAN : .........................................................................................................................

.........................................................................................................................

& *oret %ang tidak perlu


22/59



Jl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o RM) '

SURAT PERSETUJUAN TINDAKAN MEDIS

a%a ertanda tangan di a+a! ini : Nama : .......................................................................................................................Umur /kelamin : .................!r/ ln/t!. L / P Alamat : .......................................................................................................................

......................................................................................................................."ukti diri/ KTP : .......................................................................................................................Dengan ini men%atakan dengan sesunggu!n%a tela! mem erikan

PERSETUJUAN

Untuk dilakukan tindakan medis erupa ...........................................................................Ter!adap diri sa%a sendiri / istri / suami / anak / i u sa%a / apak sa%a@ dengan :

Nama : .......................................................................................................................Umur / Kelamin : ...................!r/ ln/t!. L / PAlamat : .......................................................................................................................

....................................................................................................................... "ukti diri/ KTP : ....................................................................................................................... Dira+at di : .......................................................................................................................

No. Rekam (edis : .......................................................................................................................

Bang tu#uan@ si at dan perlu tindakan medis terse ut diatas@ serta resiko %ang dapat ditim ulkan tela! cukupdi#elaskan ole! dokter dan tela! sa%a mengerti se elumn%a.

Demikian pern%ataan persetu#uan ini sa%a uat dengan penu! kesadaran dan tanpa paksaan

idoar#o@ ........................................................

aksi M saksi Dokter Bang mem uat pern%ataanTanda tangan Tanda tangan Tanda tangan

0. Petugas Kese!atan

$........................& $ ...........................& $................................& Nama terang Nama terang Nama terang

5. Pi!ak keluarga

$................................&

Nama terang& lingkari %ang etul


23/59



Jl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o RM) !

SURAT PENOLAKAN TINDAKAN MEDIS

Bang ertanda tangan di a+a! ini : Nama : ......................................................................................................... L / PPeker#aan : ............................................................................ Umur : .................!r/ ln/t!.Alamat : ......................................................................................................................

.................................................................telepon...........................................elaku pasien / keluarga terdekat pasien $ ................................................................& / penanggung #a+a

pasien dengan ini men%atakan dengan sesunggu!n%a tela! :

MENOLAK

Dilakukan tindakan medis ...........................................................................ter!adap : Nama : ..............................................................................................................L / P No. Rekam (edis : .......................................................................................................................

Dan sa%a #uga men%atakan dengan sesunggu!n%a a!+a :0. Tela! di eri pen#elasan serta peringatan akan a!a%a@ resiko serta kemungkinan8kemungkinan %ang tim ul

apa ila tidak dilakukan tindakan medis terse ut5. Tela! mema!ami sepenu!n%a pen#elasan %ang di erikan ole! Ruma! akit Ais%i%a! iti ?atima!

9. Atas tanggung #a+a dan resiko sa%a sendiri tetap ( N-LAK untuk dilakukan tindakan medisAtas penolakan ini ila ter#adi sesuatu %ang tidak diinginkan sa%a tidak akan menuntut siapapun

idoar#o@ ........................................................

Dokter R A iti ?atima! Bang men%atakan

$................................& $...........................................& Nama terang Nama terang

SAKSI

0. .............................................................$....................................& Nama terang

5. .............................................................$....................................& Nama terang


24/59



Jl. Raya Kenongo No. ! ""# "!$% ""#&'$' T(langan)S*+oa,-o RM) !A

DIA NOSA >INTER?ENSI

Nama Pasien : No. R(

. D*agno6a :e=e,a@aipertermi />ipotermi& Resiko ter#adin%a gangguan meta olisme tu u! ,angguan kesadaran ,angguan nutrisi kurang / ler i! dari ke utu!an

*emas........................................................................................................ ........................................................................................................

/. In


25/59

R U( K P RAWATAN / K "'DANAN No. R( M 0 ARU(A> AK'T A' B'BA> 'T' ?AT'(A> TULAN,AN

Nama : Umur :Ruangan : Kelas :0. Tanggal (asuk R : .......................................................................... )am : ................................5. Tanggal Keluar R : .......................................................................... )am : ................................9. Ri+a%at (asuk

Kel :

*, : Nadi : C/mnt

Tensi : / mm/>g RR : C/mnt

u!u : E* "" : ,rm/ Kg

1. (asala! kepera+atana. (asala! kepera+atan/ke idanan selama pasien dira+at

059

. (asala! kepera+atan/ ke idanan %ang dilan#utkan di ruma!059

c. (asala! (edis selama pera+atan05

9d. T!erap!% %ang dilan#utkan di ruma!

1) 5&9& 1&6& &;& 3&

6. Pemeriksaan Penun#ang (edis %ang dilakukan : La U , *T can PA

Ro K, / *>- Laparascop% Lainn%a ..................

. tatus pulang em u! Diru#uk (eninggal

"elum em u! Pulang Paksa Lainn%a ....................

;. ?ollo+ Up Kontrol Poliklinik

Tanggal : ............................... )am :...............................W'"

Karu Ruang : .................................................

Tanda tangan : .................................................

Nama Terang : .................................................

REKAM MEDIS INSTALASI RAWATINARUMA! SAKIT "AIS#I#A!$SITI %ATIMA! $

IM INAN DAERA! "AIS#I#A! SID&AR'&


26/59

R(. 0;.A

REN3ANA PELAYANAN

Nama : ...................................................L/P

Umur : ......................T!/ ln/!r

No. R(

Kelas Ruangan : ..................................

R N*ANA P LABANAN>asil Pemeriksaan :

Diagnosa $DC Ker#a@ DC Utama@ DC Pen%erta& :

Rencana Tindakan $Pemeriksaan penun#ang@ Terapi@ Tindakan / Prosedur K!usus / -perasi@ Nutrisi@Konsultasi@ Re!a ilitasi& :

Rencana (onitoring / ?ollo+ Up :

ek amping / Komplikasi %ang mungkin ter#adi / ke#adian %ang tidak di!arapkan $KTD&

>asil -ut *ome $Prognosa&

Tela! di#elaskan@ dimengerti@ dan disetu#ui

...........................aksi '

.........................aksi ''

.......................Pasien

...........................Dokter %ang mera+at

REKAM MEDIS INSTALASI RAWATINARUMA! SAKIT "AIS#I#A!

$SITI %ATIMA! $IM INAN DAERA! "AIS#I#A! SID&AR'&


27/59

R KA( ( D' 'N TALA ' RAWAT 'NAPRU(A> AK'T A' B'BA>

Q 'T' ?AT'(A> QP'(P'NAN DA RA> A' B'BA> 'D-AR)-

)l. Ra%a Kenongo no. 01 $


28/59



)l. Ra%a Kenongo no. 01 $AR'/TAN,,AL : ..................................../............................................................................... PUKUL /.T (PAT : ..................................../ ..............................................................................

ARAN8 ARAN : ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

TAN,,AL :( N, TA>U'

D-KT R BAN, ( RAWAT

................................................


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30/59



)l. Ra%a Kenongo no. 01 $ : A/"/A"/-

R'WABAT AL R,' -"AT : .........................................................................................................................................

P K R)AAN : .........................................................................................................................................

P ND'D'KAN T RAK>'R : T / D/ LP/ LA/ 0/ 5/ 9/ .........................................................................................

NA(A KK : .........................................................................................................................................

NA(A ABA> KANDUN, : ............................................... NA(A '"U KANDUN,: ............................................

NA(A UA(' / ' TR' : ..........................................................................................................................................

NA(A P RU A>AAN : ..........................................................................................................................................

N-. P ,AWA' : ..........................................................................................................................................

$ & L'N,KAR' BAN, " NAR


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33/59

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34/59


35/59

A doman : .......................................................................................................................ktremitas : .......................................................................................................................

Re laks : .......................................................................................................................Anus : ....................................................... ,enetalia : ...........................................Tonus otot : .......................................................................................................................

Tanda tangan Nama Terang

$........................................&

R KA( ( D' 'N TALA ' RAWAT 'NAP

RU(A> AK'T A' B'BA>Q 'T' ?AT'(A> QP'(P'NAN DA RA> A' B'BA> 'D-AR)-)l. Ra%a Kenongo no. 01 $epatitis *ampak

6. Pemeriksaan Tanda Jital : u!u : ............................* LD : .....................cm Nadi : ............................C/mnt LK : .....................cm RR : ...........................C/mnt

. Pemeriksaan ?isik a. Kepala D n

(ata *o+ong Tidak *o+ongklera Puti! 'cterus Pendara!an

*on#ungti4a Pucat Pink Pupil 'sokor Anisokor (iosis (idrasi>idung D n pistaCsisLida! D n Kotor >%peremi,igi D n *aries ......................(ulut D n Trismus tomatitis Lem aLe!er D n Pem esaran kelen#ar T%poid Peningkatan )JP Kaku kuduk

. 'ntegrumen : Turgor "aik Turun Luka / )e#as Tidak ada Ada : ........................................... *%anosis Tidak ada Ada : ..........................................

c. kstremitas: D n -edema Plegi Parase .............. ........... ..........

D n -edema Plegi Parase .............. ........... ..........d. Anus : ..................................................................................................................................

e. ,enetalia : .................................................................................................................................

;. Pola liminasi

"AK pt Tdk pt Alat antu .................. produksi ............cc/............

N . Rekam

/ /

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"AK Normal *air Lendir .................. produksi ............C/.............

3. Pemeriksaan Penun#ang P RAWAT P N,KA)'

a. Diagnosa :

. Pemeriksaan La :

c. Pemeriksaan Radiologi : Tanda Tangan :

d. Terapi (edis : Nama Terang :Ke AK'T A' B'BA>Q 'T' ?AT'(A> QP'(P'NAN DA RA> A' B'BA> 'D-AR)-)l. Ra%a Kenongo no. 01 $epatitis

tgl@ ..........................................

N . Rekam Me23s

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Tanda tangan dan nama terangaksi : idan / Pera+at &

$......................................................&

Tanda tangan dan nama terang' u

$......................................................&0. Kontak men%usui : ............................................menit5. Ra+at ,a ung : Penu! / Parsial &

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Keterangan : & *oret %ang tidak sesuai & )ika Ba@ *oret alat %ang tidak sesuai

R KA( ( D' 'N TALA ' RAWAT 'NAP


“SITI FATIMAH “PIMPINAN DAERAH ‘AISYIYAH SIDOARJO )l. Ra%a Kenongo no. 01 $


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........................................ ...........................................

Dokter Anestesi

........................................

R KA( ( D''N TALA ' RAWAT 'NAP

R A' B'BA>Q 'T' ?AT'(A>O

TULAN,AN

LAPORAN OPERASI R(89

0. Nama Dokter A!li "eda! : .......................................... Nama Asisten : ..........................................

Nama instrumentur : .....................................................5. Nama Dokter A!li Anestesi : ........................................ )enis Anestesi : .........................................9. Nama Dokter A!li Anak : ..............................................1. Diagnosa Pre -perasi : .............................................6. Diagnosa Post -perasi : .............................................

. )enis -perasi : .............................................

;. )aringan %ang di ksisi / 'nsisi : ................................... Dikirim untuk pemeriksaan PA Ba Tidak

Tanggal -perasi )am -perasi dimulai )am -perasi selesai Lama operasi erlangsung

Laporan -perasi : $ #ika perlu dilan#utkan di!alaman elakang &

Laporan Dokter Anak :


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Tanda tangan Dokter A!li Anestesi :

Nama Pasien : ............................................................... L/P Umur : ............................. No. R( : ...........................

Alamat : .......................................................................................................................................................................

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ore diet "K

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..................cc 51 #am

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3. . .....................................................................

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;. "ila temp. Rec 7 93 E* ........................................................................................................................

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=. "ila T %stole 2 =< mm>g ..................................................................................................................

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TertandaI

........................................

R KA( ( D''N TALA 'RAWAT 'NAP

R A' B'BA>Q 'T' ?AT'(A>O

TULAN,AN

PERSETUJUAN TINDAKANPEM0EDAHAN DAN ANESTESI

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N a m a : .............................................................................................................

Umur / )enis Kelamin : ..................... T!/ ln/!r. $ L / P &

A l a m a t : .............................................................................................................

No. R( / Ruang : ................................/ ...........................................................................

Dengan ini men%atakan dengan sesunggu!n%a tela! mem erikan

P E R S E T U J UA Untuk dilakukan tindakan Pem eda!an dan Anestesi

Ter!adap diri sa%a sendiri / suami/ istri / a%a! / i u / anak dari :

N a m a : .............................................................................................................

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A l a m a t : .............................................................................................................

No. R( / Ruang : ................................/ ...........................................................................

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........................................ ...........................................

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........................................




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RU(A> AK'T A' B'BA>

“SITI FATIMAH “ P'(P'NAN DA RA> A' B'BA> 'D-AR)-

)L. Ra%a Kenongo No. 01 $


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Nama : .............................................................La!ir di : Ruma! akit Ais%i%a! Q iti ?atima!OPada >ari / Tanggal : ............................................................ )am : ........................................"erat "adan : ..................... Kg Pan#ang : ........................................

Nama ' u : ............................................................ Umur : ......................................... Nama A%a! : ............................................................ Umur : ........................................Peker#aan : ............................................................Alamat : ............................................................

idoar#o@ ................................................... Ruma! akit Ais%i%a! iti ?atima!

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Dokter / "idan Penanggung )a+a

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R KA( ( D' 'N TALA ' RAWAT 'NAP Nomor Rekam (edis :RUMAH SAKIT ‘AISYIYAH“SITI FATIMAH “ Register :PIMPINAN DAERAH ‘AISYIYAH SIDOARJO



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; Ri+a%at pen%akit keluarga $A%a!@ ' u@ adik@ paman@ i i& %ang perna! menderita sakit : Kanker Pen%akit >ati >ipertensi D( Pen%akit ,in#al Pen%akit )i+a Kelainan "a+aan >amil Kem ar T"* pilepsi Alergi

3 Ri+a%at ,%nekologi 'n etilitas 'n eksi 4irus P( *er4isitas *ronis ndometriosis (%oma Plip er4iC Kanker Kandungan -perasi kandungan Perkosaan

=. Ri+a%a! Keluarga "erencana(etode K" %ang perna! dipakai ...................................lama.............................................

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R KA( ( D' 'N TALA ' RAWAT 'NAP Nomor Rekam (edis :RUMAH SAKIT ‘AISYIYAH“SITI FATIMAH “ Register :PIMPINAN DAERAH ‘AISYIYAH SIDOARJO

)l. Ra%a Kenongo no. 01 $is / kontraksi ......................................./ mnt teratur tidak teratur

. ,%nekologiAno ,enital

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'nspekulo : Jagina.............................portio.....................................................................................Jagina touc!er ................................................................................................................................Kesan panggul.................................................................................................................................'m ang eto pel4ic...........................................................................................................................

c. Ni as :Put ......................................*on%taksi ut :.................................Loc!ea.........................................Luka )alan Lendir ..........................................................................................................................

1 Pemeriksaan Penun#angDara! > ...............................................>t........................................Urine Protein.............................*T,...................................................................................................U , .........................................

6 D'A,N- A K "'DANAN DAN (A ALA>........................................................................................................................................................................................................................................................................................................................P NATALAK ANAAN .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

..........................................5idung D n pistaCsisLida! D n Kotor >%peremi,igi D n *aries Protesa Tanggal

(ulut D n Trismus tomatitis Lem a KeringLe!er D n Pem esaran kelen#ar T%roid Peningkatan )JP Kaku kuduk ". Dada

a. Perna asan : Normal D%speneu Lainn%a ..................... . uara na as tam a!an : Ada Tidak adac. (amae : (em esar Radang "en#oland. Putting susu : (enon#ol Datar "ersi! Kotor e. *olostum : Ada Tidak ada

*. A domen0& >%perpigmentasi

a. trae : Liurdae Al icans . Linea : Nigra Al icans

5& Palpasia. Leopoid ' : ........................................

. Leopoid '' : ........................................

N . Rekam Me23s

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c. Leopoid ''' : ........................................d. Leopoid 'J : ........................................

9& Auskultasia. *ort : .........................................

. "ising usus : .........................................C/mnt1& T?U : .........................................6& Kontraksi Uterus : .........................................

& (asa : Ada Tidak AdaD. ,enito Urinaria

a. Urinaria : pontan 'nkontinens Retensio D%suri >ematuri Terpasang D*

. Jul4a : Jarises -edem "en#olan a domenc. Perineum : 'ntake Ruptur "ekas #a!itan episd. Loc!ea : Ru ra angulente erosa Al a Purulentae. JT : ..................................................

. ktremitasa. ktremitas atas : Normal -edem Lumpu! Terpasang in us

. kstremitas a+a! : Normal -edem Lumpu! Terpasang in us Re lek patela9. Pemeriksaan Penun#ang

A. Pemeriksaan La oratorium : ...................................................................................................................................". Pemeriksaan Radiologi : ...................................................................................................................................

1. Diagnosa keluar : .......................................................................................................................................................6. Terapi : .......................................................................................................................................................

idoar#o@ ........................................................"idan %ang mengka#i

$...............................................&

0. Tanggal : ....................................................................................5. Nama "idan : .............................................................................9. Tempat persalinan :

Ruma! ' u PuskesmasPolindes Ruma! akitKlinik +asta Lainn%a. : .............................

1. Alamat tempat persalinan :6. *atatan : ru#uk@ kala : '/''/'''/'J

. Alasan meru#uk : ........................................................................;. Tempat ru#ukan : ........................................................................3. Pendamping pada saat meru#uk

"idan Temanuami duku

Keluarga tidak adaKALA '=. Partogra mele+ati garis +aspada : B/T0asiln%a : ...................................................................................KALA ''09. pisiotomi :

Ba 'ndikasi .................................................................................Tidak

01. Pendamping pada saat persalinanuami dukun

Keluarga Tidak adaTeman

06. ,a+at #anin :Ba@ tindakan %ang dilakukan :a. ..............................................................................................

. ..............................................................................................c. ..............................................................................................Tidak

0 . Distosia a!u

Ba@ tindakan %ang dilakukan :a. ..............................................................................................

51. (asase undus uteri BaTidak@ alasan : ................................................................

56. Plasenta la!ir lengkap $intact& : Ba / tidak )ika tidak lengkap@ tindakan %ang dilakukana. ..................................................................................

. ..................................................................................5 . Plasenta tidak la!ir 7 9< menit : Ba / Tidak

Ba@ tindakan :a. ...................................................................................

. ...................................................................................5;. Laserasi :

Ba@ dimana ......................................................................Tidak

53. )ika laserasi perineum@ dera#at : 0 / 5 / 9 / 1Tindakan :Pen#a!itan@ dengan / tanpa anestesiTidak di#a!it@ alasan : .....................................................

5=. Atoni Uteri :Ba@ tindakan :a. ..................................................................................

. ..................................................................................c. ..................................................................................

Tidak 9asiln%a : ......................................................................"AB' "ARU LA>'R 91. "erat adan ...........................................................gram96. Pan#ang ...................................................................cm9 . )enis kelamin : L / P9;. Penilaian a%i aru la!ir : aik / ada pen%ulit93. "a%i la!ir :

Normal@ tindakan

(engeringkan (eng!angatkan

3ATATAN PERSALINAN


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. ..............................................................................................c. ..............................................................................................Tidak

0;. (asala! lain@ se utkan : ............................................................03. Penatalaksanaan masala! terse ut : ..........................................

...................................................................................................0=. >asiln%a : ..................................................................................KALA '''5asiln%a ...................................................................................................................................................................




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1. ?ollo+ Up / kontrol di Ruma! akit Ais%i%a! iti ?atima! :

Tanggal : ................................................. )am : ....................................................................

6. Pemeriksaan / Penun#ang medis %ang dilakukan $ oto T!oraC@ La oratorium@ U ,@ *, dll& mo!on

di a+a saat kontrol

. )aga akti itas@ cukup istira!at

idoar#o@ ..................................................

Pera+at / "idan Pasien / Keluarga Pasien

........................................ ..............................................




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1 'n ormasi tentang +aktukonsultasi

6'n ormasi tentang persiapan

pasien pulang $Disc!argePlanning&

idoar#o@ ..................................................

Pera+at / "idan Pasien / Keluarga Pasien

........................................ ..............................................


52/59

R KA( ( D' 'N TALA ' RAWAT 'NAPRUMAH SAKIT ‘AISYIYAH“SITI FATIMAH “

PIMPINAN DAERAH ‘AISYIYAH SIDOARJO)l. Ra%a Kenongo no. 01 $


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“SITI FATIMAH “PIMPINAN DAERAH ‘AISYIYAH SIDOARJO



54/59

RUMAH SAKIT ‘AISYIYAH“SITI FATIMAH “

PIMPINAN DAERAH ‘AISYIYAH SIDOARJO )l. Ra%a Kenongo no. 01 $r

Alamat : ...................................................................................

Peker#aan : ...................................................................................

Pada tanggal@ ........................................................ )am ...................W'"

(eninggalkan R A iti ?atima! dengan paksa@ +alaupun kami elum

sem u! dari sakit. Kami eserta pi!ak keluarga tidak akan menga#ukan

tuntutan ter!adap pi!ak R apa ila ter#adi sesuatu !al ter!adap diri sa%a

$sepeninggal dari R &

idoar#o@ .................................... Pi!ak Keluarga@ Bang mem uat pern%ataan

........................................ ...............................................Petugas

R A iti ?atima!

..................................


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PIMPINAN DAERAH ‘AISYIYAH SIDOARJO )l. Ra%a Kenongo no. 01 $


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PIMPINAN DAERAH ‘AISYIYAH SIDOARJO)l. Ra%a Kenongo no. 01 $r

Peker#aan .....................................................................................................

Alamat .....................................................................................................

Dengan kelu!an / diagnosa sementara :

.................................................................................................................................

.................................................................................................................................

uda! kami erikan : ..............................................................................................

.................................................................................................................................

Keterangan lain : ....................................................................................................

(o!on Konsult dan T!erapi selan#utn%a.

Terima kasi!@ Wassalaam@Dokter

..................................


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R(803A


“SITI FATIMAH “PIMPINAN DAERAH ‘AISYIYAH SIDOARJO)l. Ra%a Kenongo no. 01 $


58/59

RUMAH SAKIT ‘AISYIYAH “SITI FATIMAH “

PIMPINAN DAERAH ‘AISYIYAH SIDOARJO )l. Ra%a Kenongo no. 01 $


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