Profile Pasien

Data Visit

Diagnosa

Laboratorium

Radiologi

Obat & BMHP

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Profile Pasien

Data Visit

Diagnosa

CPPT

Laboratorium

Radiologi

Obat & BMHP

---

Tindakan

Alat Kesehatan

USG

Profile Pasien

Data Visit

Diagnosa

CPPT

1. 2025-06-02 14:59

   • SUBJECTIVE :

     Nyeri post op (+)

     Gatal2 alergi (-) 

   • OBJECTIVE :

     Sens : cm 

     Vital sign dalam batas normal

      

   • ANALYST :

     Post SC 

   • PLANNING :

     Konsul via tlfn dr. Affan , Sp. OG

     Aff inj. Ceftriaxone ( pasien alergi ) 

     Inf.  Ciprofloxacin 500mg /12 jam

   • INSTRUKSI :
   Dokter Umum
2. 2025-06-02 15:00

   • SUBJECTIVE :

     OS TIBA DI VK DARI RUANG OK pkl 14 : 27 wib

     dengan keadan sadar, nyeri luka operasi (+), mual / muntah (-), demam (-)

     pendarahan (-)

   • OBJECTIVE :

     k/u cm 

     TD : 110 / 80 mmHG

     HR : 78  X/I

     RR : 18 X/I

     T : 36, 6 C

   • ANALYST :

     P3AO POST SC A/I HBSAG (+)

   • PLANNING :

     Berikan therapi sesuai 

     ivfd rl 500 + 20 ui 20 gtt/i

     ivfd rl 500 ml tramadol + fentanyl selama 6 jam

     inj metronidazole  1 fls / 8 jam

     inj ketorolac 1 ampl/ 8 jam

     inj ciprofloxacin 1 fls/12 jam

     inj as tranexsamat  500 mg / 8 jam

     vit c 2x1 

     etabion 1x1

     zink 2x1

     ketropen sub 3x1

   • INSTRUKSI :

     pantau pendarahan, ttd, urin 

   Bidan
3. 2025-06-02 21:19

   • SUBJECTIVE :

     os mengatakan nyeri luka operasi (+) demam(-) mual(-) perdarahan(+)  batuk (-) 

   • OBJECTIVE :

     td: 110/80

     hr:80x/i

     rr: 20x/i

     temp: 36,5 c

   • ANALYST :

     P3A0 POST SC A/I HBSAg (+)

   • PLANNING :

     berikan therapi sesuai advice dokter

     therapi :

     iufd rl +oksi 2 amp 

     iufd ciproploxacin 1 fls /12 jam

     metronidazol drip 1 fls/8jam

     keterolak 1 a/8jam 

     asam tranexamat 500mg /8jam

   • INSTRUKSI :
   Bidan
4. 2025-06-03 13:27

   • SUBJECTIVE :

     nyeri post operasi (+)

     BAK masih keruh, pasien susah minum

   • OBJECTIVE :

     sen : cm

     td: 110/80

     hr:80x/i

     rr: 20x/i

     temp: 36,5 c

   • ANALYST :

     P3A0 POST SC A/I HBSAg (+)

   • PLANNING :

     Teruskan Terapi

     Nanti sore pantau ulang urin, jika jernih Aff Kateter

      

   • INSTRUKSI :
   Dokter Umum
5. 2025-06-03 15:20

   • SUBJECTIVE :

     Os mengatakan nyeri bekas luka operasi (+), demam (-), mual (-), perdarahan (-)

   • OBJECTIVE :

     TD: 110/70 mmhg

     HR: 80 x/i

     RR: 20 x/i

     T: 36,2 c

   • ANALYST :

     P3A0 post sc a/i HBSAG (+)

   • PLANNING :

     Therapy:

     -IVFD RL 20 gtt/i

     -Inj Ciprofloxacin 1fls/12 jam

     -Inj Keterolac 1amp/8 jam

     -Inj Asam Tranexamat 500mg/8 jam

      

   • INSTRUKSI :

     -Anjurkan ibu mobilisasi kanan dan kiri

   Bidan
6. 2025-06-03 21:35

   • SUBJECTIVE :

     Os mengatakan nyeri bekas luka operasi (-),mual/muntah (-),demam (-)

   • OBJECTIVE :

     TD:100/70 MMHG

     HR:80 x/i

     RR:20 x/i

     T:36,5 C

   • ANALYST :

     P3A0 Post SC a/i HBSAG (+)

   • PLANNING :

     Berikan therapy sesuai advice dokter:

     -IVFD RL 20 gtt/i

     INJ.Ciprofloxacin 1fls/12 jam 

     ORAL

     -asam mefenamat 3x1

     -metronidazol 3x1

     -cefadroxil 2x1

     -etabion 2x1

     -zink 2x1

     -vit.C 2x1

   • INSTRUKSI :

     Pantau TTV

   Bidan
7. 2025-06-04 13:30

   • SUBJECTIVE :

     os mengatakan nyeri luka operasi (+),tetapi sudah berkurang, demam (-) muntah (-)

   • OBJECTIVE :

     TD:100/70 mmhg

     HR:82X/i

     RR:20X/i

     Tem:36,4 C

   • ANALYST :

     P3A0 POST SC a/i HBSAG (+)

   • PLANNING :

      pbj

     As.mefenamat 3x1

     metronidazole 3x1

     Cefadroxil 2x1

     vit c 2x1

     Etabion 2X1

   • INSTRUKSI :
   Perawat
8. 2025-06-04 10:02

   • SUBJECTIVE :

     Nyeri luka operasi berkurang

   • OBJECTIVE :

     Ttv stabil

     Luka kering

   • ANALYST :

     Post sc ai prevs sc + hep b +

   • PLANNING :

     Lapor dr. Affan, Sp. OG

     Advise

     Acc pbj

     Kontrol poli

   • INSTRUKSI :
   Dokter Umum

Laboratorium

1. DARAH LENGKAP

   2025-06-02 17:54:37
   Lihat Hasil

Radiologi

Obat & BMHP 2025-06-02 15:57:21 | Ringer Lactat / RL | - (2fls) 2025-06-02 15:57:21 | Tramadol inj | - (1Ampul) 2025-06-02 15:57:21 | Fentanil Inj. 0,05 mg/ml ampul 2 ml | - (1ampul) 2025-06-02 15:57:21 | Ketorolac inj | 1amp/8jam (1Ampul) 2025-06-02 15:57:21 | Asam Tranexamat inj | 1amp/8jam (1Ampul) 2025-06-02 15:57:21 | Metronidazole infus | 1 fls/8 jam (1botol) 2025-06-02 15:57:21 | Oxytosin inj / oksitosin / oxitosin | - (2Ampul) 2025-06-02 15:57:21 | Vitamin k | - (1Tablet) 2025-06-02 15:57:21 | HB 0 Vaksin | - (1Pcs) 2025-06-02 21:30:05 | Ringer Lactat / RL | . (2fls) 2025-06-02 21:30:05 | Ketorolac inj | 3x1 (1Ampul) 2025-06-02 21:30:05 | Asam Tranexamat inj | 500mg/8jam (1Ampul) 2025-06-02 21:30:05 | Metronidazole 500 mg | 3x1 (1tablet) 2025-06-02 21:30:05 | Oxytosin inj / oksitosin / oxitosin | . (2Ampul) 2025-06-03 13:43:59 | Ringer Lactat / RL | 20 gtt/i (2fls) 2025-06-03 13:43:59 | Ciprofloxacin larutan Infus | 1fls/12 jam (1botol) 2025-06-03 13:43:59 | Ketorolac inj | 1amp/8jam (2Ampul) 2025-06-03 13:43:59 | Asam Tranexamat inj | 500mg/8jam (2Ampul) 2025-06-03 13:43:59 | Metronidazole infus | 1 fls/8 jam (1botol) 2025-06-03 13:43:59 | Oxytosin inj / oksitosin / oxitosin | extra (2Ampul) 2025-06-03 13:43:59 | Ciprofloxacin larutan Infus | 1 FLS/12 JAM (1botol) 2025-06-03 13:43:59 | Etabion | 2 X 1 (2tablet) 2025-06-03 13:43:59 | Zink/ Zinc tab 20mg | 2 X 1 (2tablet) 2025-06-03 13:43:59 | Vitamin C | 2 X 1 (2tablet) 2025-06-03 13:43:59 | Metronidazole 500 mg | 3x1 (1tablet) 2025-06-03 13:43:59 | Asam Mefenamat 500mg | 3x1 (1Pcs) 2025-06-03 13:43:59 | Cefadroxil Monohydrate 500mg | 2 X 1 (1tablet) 2025-06-04 10:43:21 | Asam Mefenamat 500mg | 3x1 (10Pcs) 2025-06-04 10:43:21 | Cefadroxil Monohydrate 500mg | 2x1 (10tablet) 2025-06-04 10:43:21 | Metronidazole 500 mg | 3x1 (10tablet) 2025-06-04 10:43:21 | Vitamin C | 2x1 (10tablet) 2025-06-04 10:43:21 | Tablet tambah darah | 2x1 (10Tablet)

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2025-06-02 16:04:01 | Selang Oxygen Bayi | - (1pcs) 2025-06-02 16:04:01 | Suction Cateter No.8 | - (1pcs) 2025-06-02 16:04:01 | Kasa Hydrophil Steril Uk 16 cm x 16 cm | - (1box) 2025-06-02 16:04:01 | Alat suntik sekali pakai spuit 1 cc | - (1pcs) 2025-06-02 16:04:01 | abocath/ IV Catheter No.24 | - (1pcs) 2025-06-02 16:04:01 | abocath/ IV Catheter No.22 | - (1pcs) 2025-06-02 16:04:01 | Alat suntik sekali pakai spuit 5 cc | - (1pcs) 2025-06-02 16:04:01 | Alat suntik sekali pakai spuit 3 cc | - (2pcs) 2025-06-02 16:04:01 | abocath/ IV Catheter No.20 | - (1pcs) 2025-06-02 16:04:01 | Blood Transfusion Set | - (1pcs) 2025-06-02 21:33:29 | Alat suntik sekali pakai spuit 10 cc | . (1pcs) 2025-06-02 21:33:29 | Alat suntik sekali pakai spuit 3 cc | . (1pcs) 2025-06-03 13:48:34 | Alat suntik sekali pakai spuit 3 cc | - (2pcs) 2025-06-03 13:48:34 | Alat suntik sekali pakai spuit 3 cc | - (1pcs) 2025-06-03 13:48:34 | Nald No.23 | - (1pcs)

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