Riwayat Pasien

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Tanggal Visit No.Pendaftaran Poliklinik Jaminan Usia Dokter Diagnosa Sumber Actions
1 2025-05-06 11:48:14 OK-20250505578 OK BPJS Kesehatan 30 tahun 6 bulan 27 hari dr. ERY SUHAYMI, Sp. B
Poliklinik
2 2025-05-05 13:33:02 OK-20250505167 OK BPJS Kesehatan 30 tahun 6 bulan 26 hari dr. ERY SUHAYMI, Sp. B
IGD
3 2025-05-05 13:01:00 RI-20250505147 RI BPJS Kesehatan 30 tahun 6 bulan 29 hari dr. ERY SUHAYMI, Sp. B
  • 53.00 | Unilateral repair of inguinal hernia, not otherwise specified
  • K40.0 | Bilateral inguinal hernia, with obstruction, without gangrene Primer
RI

Td : 120/80 Mmhg

Hr : 80x/i

Rr : 20x/i

Temp : 36,5c 

peristaltik (+)

  • ANALYST :

    HIL (R) Reponibel

  • PLANNING :

    BEsok GV, jika kering dan KU stabil  PBJ

    Cefixime 2x200mg,

    Na diclofenac 3x1,

    metronidazole 3x1

  • INSTRUKSI :
  • Dokter Umum
  • 2025-05-06 23:42
    • SUBJECTIVE :

      Os mengatakan nyeri post operasi berkurang

    • OBJECTIVE :

      Os tampak istirahat 

      Td : 120/80 Mmhg

      Hr : 80x/i

      Rr : 20x/i

      Temp : 36,5c 

    • ANALYST :

      Gangguan intoleransi aktivitas 

    • PLANNING :

      Kolaborasi dengan dokter pemberian therapy

    • INSTRUKSI :
    Perawat
  • 2025-05-07 15:44
    • SUBJECTIVE :

      Os mengatakan nyeri post operasi berkurang

    • OBJECTIVE :

      Os tampak istirahat 

      Td : 100/80 Mmhg

      Hr : 80x/i

      Rr : 20x/i

      Temp : 36,5c 

    • ANALYST :

      Gangguan intoleransi aktivitas 

    • PLANNING :

      Kolaborasi dengan dokter pemberian therapy

    • INSTRUKSI :
    Perawat
  • 2025-05-07 16:27
    • SUBJECTIVE :

      nyeri luka operasi berkurang, flattus +

       

    • OBJECTIVE :

      ttv stabil

      peristaltik (+)

    • ANALYST :

      post op HIL (R) Reponibel

    • PLANNING :

      Aff kateter urin

      pantau luka jika KU stabil PBJ besok

      Cefixime 2x200mg,

      Na diclofenac 3x1,

      metronidazole 3x1

    • INSTRUKSI :
    Dokter Umum
  • 2025-05-08 12:29
    • SUBJECTIVE :

      nyeri luka operasi berkurang, flattus +

       

    • OBJECTIVE :

      ttv stabil

      peristaltik (+)

    • ANALYST :

      post op HIL (R) Reponibel

    • PLANNING :

       PBJ 

      Cefixime 2x200mg,

      Na diclofenac 3x1,

      metronidazole 3x1

    • INSTRUKSI :
    Dokter Umum
  • Obat & BMHP 2025-05-05 22:26:57 | Ringer Lactat / RL | _ (2fls) 2025-05-05 22:26:57 | Ketorolac inj | _ (2Ampul) 2025-05-05 22:26:57 | Ranitidin inj | _ (2Ampul) 2025-05-05 22:26:57 | Ceftiaxiason inj | _ (1Vial) 2025-05-05 22:26:57 | Asam Tranexamat | _ (1tablet) 2025-05-06 12:31:39 | Ringer Lactat / RL | 20gtt/i (1fls) 2025-05-06 12:31:39 | Ceftiaxiason inj | Per12jam (1Vial) 2025-05-06 12:31:39 | Ketorolac inj | Per8jam (1Ampul) 2025-05-06 12:31:39 | Ranitidin inj | Per12jam (1Ampul) 2025-05-06 12:31:39 | Aqua pro injection | Pcs (1Vial) 2025-05-06 23:43:18 | Ringer Lactat / RL | 20gtt/i (1fls) 2025-05-06 23:43:18 | Ceftiaxiason inj | 1gr/12 jam (1Vial) 2025-05-06 23:43:18 | Ranitidin inj | per 12 jam (1Ampul) 2025-05-06 23:43:18 | Ketorolac inj | per 8 jam (1Ampul) 2025-05-06 23:43:18 | Asam Tranexamat inj | per 12 jam (1Ampul) 2025-05-07 15:44:38 | Ringer Lactat / RL | 20gtt/i (1fls) 2025-05-07 15:44:38 | Ketorolac inj | per8jam (1Ampul) 2025-05-07 15:44:38 | Ranitidin inj | per12jam (1Ampul) 2025-05-07 15:44:38 | Ceftiaxiason inj | per12jam (1Vial) 2025-05-07 15:44:38 | Asam Tranexamat inj | per12jam (1Ampul) 2025-05-07 15:44:38 | Aqua pro injection | pcs (1Vial) 2025-05-08 13:49:39 | Cefixime 200 mg | 2x200mg (14tablet) 2025-05-08 13:49:39 | Natrium Diklofenak 50 mg / nadic | 3x1 (21tablet) 2025-05-08 13:49:39 | Metronidazole 500 mg | 3x1 (21tablet) 2025-05-08 13:51:10 | Ringer Lactat / RL | 20gtt/i (1fls) 2025-05-08 13:51:10 | Ranitidin inj | Per12jam (1Ampul) 2025-05-08 13:51:10 | Ketorolac inj | Per8jam (1Ampul) 2025-05-08 13:51:10 | Asam Tranexamat inj | Per12jam (1Ampul) 2025-05-08 13:51:10 | Ceftiaxiason inj | Per12jam (1Vial)
    2025-05-05 22:27:59 | Alat suntik sekali pakai spuit 3 cc | _ (2pcs) 2025-05-05 22:27:59 | Alat suntik sekali pakai spuit 10 cc | _ (1pcs) 2025-05-05 22:27:59 | Alat suntik sekali pakai spuit 5 cc | _ (1pcs) 2025-05-06 12:33:59 | Alat suntik sekali pakai spuit 10 cc | Per12jam (1pcs) 2025-05-06 12:33:59 | Alat suntik sekali pakai spuit 3 cc | Per12jam (1pcs) 2025-05-06 12:33:59 | Alat suntik sekali pakai spuit 3 cc | Per8jam (1pcs) 2025-05-06 23:44:43 | Alat suntik sekali pakai spuit 10 cc | per 12 jam (1pcs) 2025-05-06 23:44:43 | Alat suntik sekali pakai spuit 3 cc | per 12 jam (1pcs) 2025-05-06 23:44:43 | Alat suntik sekali pakai spuit 3 cc | per 8 jam (1pcs) 2025-05-06 23:44:43 | Alat suntik sekali pakai spuit 5 cc | per 12 jam (1pcs) 2025-05-07 15:46:37 | Alat suntik sekali pakai spuit 10 cc | per12jam (1pcs) 2025-05-07 15:46:37 | Alat suntik sekali pakai spuit 5 cc | per12jam (1pcs) 2025-05-07 15:46:37 | Alat suntik sekali pakai spuit 3 cc | per8jam (1pcs) 2025-05-07 15:46:37 | Alat suntik sekali pakai spuit 3 cc | per12jam (1pcs) 2025-05-08 13:53:49 | Alat suntik sekali pakai spuit 10 cc | Per12jam (1pcs) 2025-05-08 13:53:49 | Alat suntik sekali pakai spuit 3 cc | Per12jam (1pcs) 2025-05-08 13:53:49 | Alat suntik sekali pakai spuit 3 cc | Per8jam (1pcs) 2025-05-08 13:53:49 | Alat suntik sekali pakai spuit 5 cc | Per12jam (1pcs)
    Tanggal Rencana Kontrol No.Pendaftaran Catatan Status
    2025-05-15 RI-20250505147 Kontrol ulang Belum Kontrol