Riwayat Pasien

  2. Registrasi Awal
  3. Riwayat Pasien
...
Tanggal Visit No.Pendaftaran Poliklinik Jaminan Usia Dokter Diagnosa Sumber Actions
1 2025-04-14 01:05:36 IGD-20250414115 IGD BPJS Kesehatan 25 tahun 6 bulan 11 hari dr. Ayuda Suha
  • K35.9 | Acute appendicitis, unspecified
  • K35.9 | Acute appendicitis, unspecified Primer
IGD
2 2025-04-14 12:50:06 OK-20250414675 OK BPJS Kesehatan 25 tahun 6 bulan 11 hari dr. ERY SUHAYMI, Sp. B
RI
3 2025-04-16 21:42:05 OK-20250416891 OK BPJS Kesehatan 25 tahun 6 bulan 13 hari dr. SUWANDY EKA SYAHPUTRA, Sp.B
RI
4 2025-04-14 01:59:38 RI-20250414115 RI BPJS Kesehatan 25 tahun 6 bulan 19 hari dr. SUWANDY EKA SYAHPUTRA, Sp.B
  • 54.11 | Exploratory laparotomy
  • K65.0 | Acute peritonitis Primer
RI

Beri posisi yg nyaman
Pantau perdarahan
Rawat luka
Kolaborasi dokter
ivfd RL 30 tpm
iufd .B.fluid / hari
inj.ceftriaxone 1gr/12jam
inj.ketorolax 1 amp/8jam
inj.ranitidin 1amp./12jam  

 

 

-
  • INSTRUKSI :
    • Perawat
  • 2025-04-19 11:48
    • SUBJECTIVE :

      os mengatakan nyeri luka post op (+) lemas (+)

    • OBJECTIVE :

      TD:110/85mmhg

      RR:22x/menit

      HR:89x/menit

      TEMP:36,5 C

      SPO2:99% tanpa o2

    • ANALYST :

      Nyeri akut b/d post operasi

    • PLANNING :

      Beri posisi yg nyaman
      Pantau perdarahan
      Rawat luka
      Kolaborasi dokter
      ivfd RL 30 tpm
      iufd .B.fluid / hari
      inj.ceftriaxone 1gr/12jam
      inj.ketorolax 1 amp/8jam
      inj.ranitidin 1amp./12jam 

      metronidazole drip 500mg/12 jam 

      b-fluid1fls/hari 

      inj. ondansetrone 1a/8jam  

       

       

      -
    • INSTRUKSI :
    Perawat
  • 2025-04-19 12:17
    • SUBJECTIVE :

      nyeri luka operasi +

      mual -

      muntah -

      demam -

      puasa +

    • OBJECTIVE :

      sen cm

      TD:110/85mmhg

      RR:22x/menit

      HR:89x/menit

      TEMP:36,5 C

      SPO2:99% tanpa o2

      produksi urin +/- 600 cc warna kekuningan 

    • ANALYST :

      post op laparatomi H3 a/i appedicitis perforasi

       

    • PLANNING :

      puasa hari ke tiga

       ganti perban /3 hari

      pinru setelah ganti perban 

      terapi lain lanjut

    • INSTRUKSI :
    Dokter Umum
  • 2025-04-19 18:47
    • SUBJECTIVE :

      os mengtakan nyeri di area oprasi 

    • OBJECTIVE :

      TD:110/85mmhg

      RR:22x/menit

      HR:89x/menit

      TEMP:36,5 C

      SPO2:99% tanpa o2

    • ANALYST :

      gangguan rasa nyaman 

      nyeri akut (+)

    • PLANNING :

      pantau ttv 

      berikan posisi yang nyaman 

      kolaborasi dengan dokter 

      iufd kaen 3b 30 tpm 

      inj.ceftriaxone 1g/12jam 

      inj.ranitidin 1a/12jam

      inj.ondan 1a/12jam

      inj.ketorolax 1a/8jam 

      bfluid 1f/hari 

       

    • INSTRUKSI :
    Perawat
  • 2025-04-19 23:05
    • SUBJECTIVE :

      os tiba diruabgan rawat inap pada pukul 20.30 wib dzri icu dengan keluhan mengtakan nyeri luka post op

    • OBJECTIVE :

      Os tampak meringis kesakitanTD:110/85mmhg

      RR:22x/menit

      HR:89x/menit

      TEMP:36,5 C

    • ANALYST :

      gangguan rasa nyaman 

      nyeri akut (+)

    • PLANNING :

      pantau ttv 

      berikan posisi yang nyaman 

      kolaborasi dengan dokter dalam pemberian therapy

    • INSTRUKSI :
    Perawat
  • 2025-04-20 11:57
    • SUBJECTIVE :

      Nyeri luka operasi berkurang

      Flatus +

    • OBJECTIVE :

      Ttv stabil

      Abdomen : Terpasang Drain +, darah + pus

    • ANALYST :

      Post laparatomi ec Appendicitis perforasi

    • PLANNING :

      Terapi lanjut

    • INSTRUKSI :
    Dokter Umum
  • 2025-04-20 12:41
    • SUBJECTIVE :

      os mengatakan Nyeri luka operasi berkurang

       

    • OBJECTIVE :

      Os tampak beristirahat

      td:90/60 mmhg

      hr:80 x/i

      rr:23 x/i

      t:36,6 c

    • ANALYST :

      gangguan hambatan mobilitas fisik

    • PLANNING :

      Terapi lanjut

    • INSTRUKSI :
    Perawat
  • 2025-04-20 18:46
    • SUBJECTIVE :

      os mengatakan Nyeri luka operasi berkurang

       

    • OBJECTIVE :

      Os tampak beristirahat

      td:90/60 mmhg

      hr:80 x/i

      rr:23 x/i

      t:36,6 c

    • ANALYST :

      gangguan hambatan mobilitas fisik

    • PLANNING :

      kolaborasi dengan dokter dalam pemberian therapy

    • INSTRUKSI :
    Perawat
  • 2025-04-21 10:23
    • SUBJECTIVE :

      nyeri berkurang

    • OBJECTIVE :

      drain produksi minimal

    • ANALYST :

      post laparotomi

    • PLANNING :

      - aff drain

      - aff kateter urin

      - GV

      - Terapi teruskan

      - Besok PBJ terapi cefixime 2x200mg, metronidazole 3x500mg, na diclofenac 3x1, ranitdin 3x1

    • INSTRUKSI :
    Dokter Spesialis
  • 2025-04-21 15:32
    • SUBJECTIVE :

      os mengatakan Nyeri luka operasi berkurang

       

    • OBJECTIVE :

      Os tampak beristirahat

      td:90/60 mmhg

      hr:80 x/i

      rr:23 x/i

      t:36,6 c

    • ANALYST :

      gangguan hambatan mobilitas fisik

    • PLANNING :

      kolaborasi dengan dokter dalam pemberian therapy

    • INSTRUKSI :
    Perawat
  • 2025-04-21 23:06
    • SUBJECTIVE :

      os mengatakan Nyeri luka operasi berkurang

       

    • OBJECTIVE :

      Os tampak beristirahat

      td:100/80 mmhg

      hr:80 x/i

      rr:23 x/i

      t:36,6 c

    • ANALYST :

      gangguan hambatan mobilitas fisik

    • PLANNING :

      kolaborasi dengan dokter dalam pemberian therapy

    • INSTRUKSI :
    Perawat
  • 2025-04-22 10:15
    • SUBJECTIVE :

      os mengatakan Nyeri luka operasi berkurang

       

    • OBJECTIVE :

      Os tampak beristirahat

      td:110/80 mmhg

      hr:83 x/i

      rr:23 x/i

      t:36,6 c

    • ANALYST :

      gangguan hambatan mobilitas fisik

    • PLANNING :

      kolaborasi dengan dokter dalam pemberian therapy

    • INSTRUKSI :
    Perawat
  • 2025-04-22 11:38
    • SUBJECTIVE :

      nyeri luka operasi (+) berkurang

      luka operasi kering

    • OBJECTIVE :

      sen : cm

      Td : 110/70

      Hr : 87

      Rr : 19

      T : 36,7

    • ANALYST :

      Post Laparotomi

    • PLANNING :

      Pbj

      cefixime 2x200mg

      metronidazole 3x500mg,

      na diclofenac 3x1

      ranitdin 3x1

    • INSTRUKSI :
    Dokter Umum
  • 2025-04-22 12:02:48
    • SUBJECTIVE : Adime
    • OBJECTIVE :

      Td : 110/70 mmHg

      Hr : 87 x/i

      Rr : 19 x/i

      T : 36,7 c

      -

      Pemenuhan kebutuhan gizi pasien berkaitan dengan penyakit yang diderita pasien  

    • ANALYST :

      Diet Makanan Saring (MI)

    • PLANNING :

      Monitoring asupan makan pasien

      -

      Asupan makan

    • INSTRUKSI :
    Ahli Gizi
  • 2025-04-16 16:34
    • SUBJECTIVE :

      Sakit perut lebih kurang 10 hari

    • OBJECTIVE :

      Abdomen
      I: Cembung
      P: Defans muscular +

    • ANALYST :

      Peritamitis Generalisata ec Perforasi Caecum Adhesiolisis luas

      Post laparotomy explorasi + primary suture caecum +  Adhesiolisis luas

    • PLANNING :

      Pausa 3 hari ( TPN )

      Hari I : Ivfd rl 30 gtt/i
      Hari II, III, IV : Inf Bfluid 1 fls / hari
                               Inf Kaen 3 B 30 gtt/i
      Inj Ceftriaxone 1gr / 12 jam
       Inf Metrodinazole 500 mg / 8 jam
      Inj ketorolac 30 mg / 8 jam
      Inj ranitidine 50 mg / 12 jam
      Inj Ondansentron 4 mg / 12 jam

      Gv / 3 hari

    • INSTRUKSI :
    Dokter Spesialis
    • Laboratorium
    1. URINE LENGKAP
      2025-04-15 15:57:05
      Lihat Hasil
    Radiologi
    1. Appendicografi
      2025-04-14 03:03:56
      Sedang Proses
    Obat & BMHP 2025-04-14 12:17:06 | Ceftiaxiason inj | 12jam (1Vial) 2025-04-14 12:17:06 | Ringer Lactat / RL | 20 gtt/i (1fls) 2025-04-14 12:17:06 | Ketorolac inj | 8 jam (1Ampul) 2025-04-14 12:17:06 | Ranitidin inj | 12 jam (1Ampul) 2025-04-14 20:17:33 | Ringer Lactat / RL | 20gtt/i (2fls) 2025-04-14 20:17:33 | Ceftiaxiason inj | per12jam (1Vial) 2025-04-14 20:17:33 | Ranitidin inj | per12jam (1Ampul) 2025-04-14 20:17:33 | Ketorolac inj | per8jam (2Ampul) 2025-04-14 20:17:33 | Aqua pro injection | pcs (1Vial) 2025-04-15 09:18:26 | Ringer Lactat / RL | 20gtt/i (2fls) 2025-04-15 09:18:26 | Ceftiaxiason inj | 12 (1Vial) 2025-04-15 09:18:26 | Ranitidin inj | 12 jam (1Ampul) 2025-04-15 09:18:26 | Ketorolac inj | 8jam (2Ampul) 2025-04-15 18:48:52 | Ringer Lactat / RL | 20 gtt/i (1fls) 2025-04-15 18:48:52 | Ceftiaxiason inj | 12 jam (1Vial) 2025-04-15 18:48:52 | Ketorolac inj | 8 jam (1Ampul) 2025-04-15 18:48:52 | Ranitidin inj | 12 jam (1Ampul) 2025-04-16 11:51:38 | Ringer Lactat / RL | 20gtt/i (1fls) 2025-04-16 11:51:38 | Ceftiaxiason inj | 1gr / 12 jam (1Vial) 2025-04-16 11:51:38 | Ranitidin inj | Per 12 jam (1Ampul) 2025-04-16 11:51:38 | Ketorolac inj | Per 8 jam (1Ampul) 2025-04-16 21:33:37 | Ringer Lactat / RL | 20gtt/i (1fls) 2025-04-16 21:33:37 | Ceftiaxiason inj | 12 jam (1Vial) 2025-04-16 21:33:37 | Ketorolac inj | 8 jam (2Ampul) 2025-04-16 21:33:37 | Ranitidin inj | 12 jam (1Ampul) 2025-04-17 09:17:56 | Ringer Lactat / RL | - (1fls) 2025-04-17 09:17:56 | Ceftiaxiason inj | /12jam (1Vial) 2025-04-17 09:17:56 | Ranitidin inj | /12jam (1Ampul) 2025-04-17 09:17:56 | Ketorolac inj | /8jam (1Ampul) 2025-04-17 09:17:56 | Metronidazole infus | /8jam (1botol) 2025-04-17 18:23:36 | Ceftiaxiason inj | /12jam (1Vial) 2025-04-17 18:23:36 | Bfluid / Aminofluid | 24 jam (1fls) 2025-04-17 18:23:36 | Ondansentron inj | /12jam (1Ampul) 2025-04-17 18:23:36 | Ketorolac inj | /8jam (2Ampul) 2025-04-17 18:23:36 | Metronidazole infus | /8jam (2botol) 2025-04-17 18:23:36 | Ranitidin inj | /12jam (1Ampul) 2025-04-17 18:23:36 | Ringer Lactat / RL | /12jam (1fls) 2025-04-18 08:46:37 | Ringer Lactat / RL | - (1fls) 2025-04-18 08:46:37 | Ceftiaxiason inj | /12jam (1Vial) 2025-04-18 08:46:37 | Ranitidin inj | /12jam (1Ampul) 2025-04-18 08:46:37 | Ketorolac inj | /8jam (1Ampul) 2025-04-18 08:46:37 | Metronidazole infus | /8jam (1botol) 2025-04-18 08:46:37 | Ondansentron inj | /8jam (1Ampul) 2025-04-18 08:46:37 | Cairan KN-3B/ kaen 3b/ ka-en 3b | - (1fls) 2025-04-18 17:51:03 | Ceftiaxiason inj | /12jam (1Vial) 2025-04-18 17:51:03 | Ketorolac inj | /8jam (2Ampul) 2025-04-18 17:51:03 | Ondansentron inj | /8jam (2Ampul) 2025-04-18 17:51:03 | Ranitidin inj | /12jam (1Ampul) 2025-04-18 17:51:03 | Bfluid / Aminofluid | /24 jam (1fls) 2025-04-18 17:51:03 | Cairan KN-3B/ kaen 3b/ ka-en 3b | /8jam (3fls) 2025-04-18 17:51:03 | Ringer Lactat / RL | /8jam (2fls) 2025-04-19 11:49:55 | Cairan KN-3B/ kaen 3b/ ka-en 3b | - (1fls) 2025-04-19 11:49:55 | Ketorolac inj | /8jam (1Ampul) 2025-04-19 11:49:55 | Ceftiaxiason inj | /12jam (1Vial) 2025-04-19 11:49:55 | Metronidazole infus | /8jam (1botol) 2025-04-19 11:49:55 | Ondansentron inj | /8jam (1Ampul) 2025-04-19 11:49:55 | Aqua pro injection | - (1Vial) 2025-04-19 18:54:32 | Ceftiaxiason inj | /12jam (1Vial) 2025-04-19 18:54:32 | Ranitidin inj | /12jam (1Ampul) 2025-04-19 18:54:32 | Ondansentron inj | /12jam (1Ampul) 2025-04-19 18:54:32 | Ketorolac inj | /8jam (2Ampul) 2025-04-19 18:54:32 | Metronidazole infus | /8jam (2botol) 2025-04-19 18:54:32 | Cairan KN-3B/ kaen 3b/ ka-en 3b | /8jam (3fls) 2025-04-20 12:44:07 | Ringer Lactat / RL | 20gtt/i (1fls) 2025-04-20 12:44:07 | Ceftiaxiason inj | per12jam (1Vial) 2025-04-20 12:44:07 | Ranitidin inj | per12jam (1Ampul) 2025-04-20 12:44:07 | Metronidazole infus | per8jam (1botol) 2025-04-20 12:44:07 | Bfluid / Aminofluid | perhari (1fls) 2025-04-20 12:44:07 | Ondansentron inj | per8jam (1Ampul) 2025-04-20 12:44:07 | Aqua pro injection | pcs (1Vial) 2025-04-20 18:46:50 | Ringer Lactat / RL | 20gtt/i (1fls) 2025-04-20 18:46:50 | Ceftiaxiason inj | 1gr/12jam (1Vial) 2025-04-20 18:46:50 | Ranitidin inj | per 12 jam (1Ampul) 2025-04-20 18:46:50 | Cairan KN-3B/ kaen 3b/ ka-en 3b | 20gtt/i (1fls) 2025-04-20 18:46:50 | Metronidazole infus | Per 8 Jam (2botol) 2025-04-20 18:46:50 | Ondansentron inj | Per 8 Jam (2Ampul) 2025-04-21 15:32:27 | Ringer Lactat / RL | fls (1fls) 2025-04-21 15:32:27 | Ceftiaxiason inj | 1gr/12jam (1Vial) 2025-04-21 15:32:27 | Ranitidin inj | 50 mg/12jam (1Ampul) 2025-04-21 15:32:27 | Metronidazole infus | 500mg/8 jam (1botol) 2025-04-21 15:32:27 | Ondansentron inj | 4mg/8jam (1Ampul) 2025-04-21 15:32:27 | Ketorolac inj | 30mg/8 jam (1Ampul) 2025-04-21 23:07:36 | Ringer Lactat / RL | 20gtt/i (2fls) 2025-04-21 23:07:36 | Metronidazole infus | per8jam (2botol) 2025-04-21 23:07:36 | Ceftiaxiason inj | per12jam (1Vial) 2025-04-21 23:07:36 | Omeprazole inj | per 12 jam (1Ampul) 2025-04-21 23:07:36 | Ondansentron inj | per8jam (2Ampul) 2025-04-22 10:16:47 | Ringer Lactat / RL | 20gtt/i (1fls) 2025-04-22 10:16:47 | Bfluid / Aminofluid | 24jam (1fls) 2025-04-22 10:16:47 | Metronidazole infus | 8 jam (1botol) 2025-04-22 10:16:47 | Ceftiaxiason inj | 12 jam (1Vial) 2025-04-22 10:16:47 | Omeprazole inj | 12 jam (1Ampul) 2025-04-22 10:16:47 | Ondansentron inj | 8 jam (1Ampul) 2025-04-22 15:58:03 | Cefixime 200 mg | 2x200mg (14tablet) 2025-04-22 15:58:03 | Metronidazole 500 mg | 3x500mg (21tablet) 2025-04-22 15:58:03 | Natrium Diklofenak 50 mg / nadic | 3x1 (21tablet) 2025-04-22 15:58:03 | Ranitidin HCl 150 mg | 3x1 (21Pcs)
    2025-04-14 12:18:23 | Alat suntik sekali pakai spuit 10 cc | 12 jam (1pcs) 2025-04-14 12:18:23 | Alat suntik sekali pakai spuit 3 cc | 8jam (1pcs) 2025-04-14 12:18:23 | Alat suntik sekali pakai spuit 3 cc | 12 jam (1pcs) 2025-04-14 20:20:19 | Alat suntik sekali pakai spuit 10 cc | per12jam (1pcs) 2025-04-14 20:20:19 | Alat suntik sekali pakai spuit 3 cc | per12jam (1pcs) 2025-04-14 20:20:19 | Alat suntik sekali pakai spuit 3 cc | per8jam (2pcs) 2025-04-15 09:19:45 | Alat suntik sekali pakai spuit 10 cc | 12 (1pcs) 2025-04-15 09:19:45 | Alat suntik sekali pakai spuit 3 cc | 12 (1pcs) 2025-04-15 09:19:45 | Alat suntik sekali pakai spuit 3 cc | 8j (2pcs) 2025-04-15 18:49:57 | Alat suntik sekali pakai spuit 10 cc | 12 jam (1pcs) 2025-04-15 18:49:57 | Alat suntik sekali pakai spuit 3 cc | 8 jam (1pcs) 2025-04-15 18:49:57 | Alat suntik sekali pakai spuit 3 cc | 12 jam (1pcs) 2025-04-16 11:52:34 | Alat suntik sekali pakai spuit 10 cc | Per 12 jam (1pcs) 2025-04-16 11:52:34 | Alat suntik sekali pakai spuit 3 cc | Pcs (2pcs) 2025-04-16 21:34:29 | Alat suntik sekali pakai spuit 10 cc | 12 jam (1pcs) 2025-04-16 21:34:29 | Alat suntik sekali pakai spuit 3 cc | 8 jam (2pcs) 2025-04-16 21:34:29 | Alat suntik sekali pakai spuit 3 cc | 12 jam (1pcs) 2025-04-17 09:19:26 | Alat suntik sekali pakai spuit 10 cc | - (1pcs) 2025-04-17 09:19:26 | Alat suntik sekali pakai spuit 3 cc | - (2pcs) 2025-04-17 18:26:49 | Alat suntik sekali pakai spuit 10 cc | /12jam (2pcs) 2025-04-17 18:26:49 | Alat suntik sekali pakai spuit 3 cc | /8jam (3pcs) 2025-04-18 08:50:08 | Alat suntik sekali pakai spuit 10 cc | - (2pcs) 2025-04-18 08:50:08 | Alat suntik sekali pakai spuit 3 cc | - (2pcs) 2025-04-18 17:50:22 | Alat suntik sekali pakai spuit 10 cc | /12jam (2pcs) 2025-04-18 17:50:22 | Alat suntik sekali pakai spuit 3 cc | /8jam (2pcs) 2025-04-18 17:50:22 | Alat suntik sekali pakai spuit 3 cc | 8 jam (1pcs) 2025-04-19 11:51:44 | Alat suntik sekali pakai spuit 3 cc | - (3pcs) 2025-04-19 11:51:44 | Alat suntik sekali pakai spuit 10 cc | - (1pcs) 2025-04-19 18:53:45 | Alat suntik sekali pakai spuit 10 cc | /12jam (1pcs) 2025-04-19 18:53:45 | Alat suntik sekali pakai spuit 3 cc | /8jam (3pcs) 2025-04-20 13:06:46 | Alat suntik sekali pakai spuit 10 cc | per 12 jam (1pcs) 2025-04-20 13:06:46 | Alat suntik sekali pakai spuit 3 cc | per 12 jam (1pcs) 2025-04-20 13:06:46 | Alat suntik sekali pakai spuit 3 cc | per8jam (1pcs) 2025-04-20 18:48:08 | Alat suntik sekali pakai spuit 10 cc | per 12 jam (1pcs) 2025-04-20 18:48:08 | Alat suntik sekali pakai spuit 3 cc | - (3pcs) 2025-04-21 15:33:45 | Alat suntik sekali pakai spuit 10 cc | - (1pcs) 2025-04-21 15:33:45 | Alat suntik sekali pakai spuit 3 cc | - (2pcs) 2025-04-21 23:10:13 | Alat suntik sekali pakai spuit 10 cc | per12jam (1pcs) 2025-04-21 23:10:13 | Alat suntik sekali pakai spuit 5 cc | per12jam (1pcs) 2025-04-21 23:10:13 | Alat suntik sekali pakai spuit 3 cc | per8jam (2pcs) 2025-04-22 10:18:55 | Alat suntik sekali pakai spuit 10 cc | 12 jam (1pcs) 2025-04-22 10:18:55 | Alat suntik sekali pakai spuit 5 cc | 12 jam (1pcs)
    Tindakan
    Alat Kesehatan
    USG
    Tanggal Rencana Kontrol No.Pendaftaran Catatan Status
    2025-04-30 RI-20250414115 Belum Kontrol
    2025-04-30 RI-20250414115 Belum Kontrol