| No. |
Tanggal |
Profesi |
Nama |
ASSESMEN |
| 1 |
2024-04-24 04:45:06 |
Perawat |
DANI WINDY |
- S (SUBJECTIVE)
pasien tiba diruangan anak pukul 04.45 wib demam(+),mencret(+). - O (OBJECTIVE)
HR:149x/i
RR:44x/i
T :39,7C
BB:5,1 kg - A (ANALYST)
gangguan mobilitas fisik - P (PLANNING)
kolaborasi dengan dokter Sp.A - I (INSTRUKSI)
|
| 2 |
2024-04-24 08:30:47 |
Perawat |
NUR HAWANI |
- S (SUBJECTIVE)
demam(+),mencret(+) - O (OBJECTIVE)
HR:149x/i
RR:44x/i
T :38,3C
BB:5,1 kg - A (ANALYST)
gangguan mobilitas fisik - P (PLANNING)
kolaborasi dengan dokter Sp.A - I (INSTRUKSI)
|
| 3 |
2024-04-24 11:30:36 |
Dokter Spesialis |
dr. Nur Zahara Sp.A |
- S (SUBJECTIVE)
mencret >5x
- O (OBJECTIVE)
sens:cm
T:38,3C - A (ANALYST)
GE dgn DRS - P (PLANNING)
IVFD rl 60 gtt/i micro
selama 6 jam selanjutnya 15 gtt/imicro
cefotaxim inj,200mg/8jam/iv
pct drip 70 mg/6jam
L-BIO 2X1 sahet - I (INSTRUKSI)
cek feces rutin
|
| 4 |
2024-04-24 18:30:08 |
Perawat |
DANI WINDY |
- S (SUBJECTIVE)
demam(-),mencret(+)
- O (OBJECTIVE)
HR:149x/i
RR:44x/i
T :37C
BB:5,1kg - A (ANALYST)
gangguan mobilitas fisik - P (PLANNING)
kolaborasi dengan dokter Sp.A - I (INSTRUKSI)
|
| 5 |
2024-04-25 08:30:15 |
Perawat |
NUR HAWANI |
- S (SUBJECTIVE)
demam(-),mencret(+) - O (OBJECTIVE)
HR:149x/i
RR:44x/i
T :37 C
BB:5,2 kg - A (ANALYST)
gangguan mobilitas fisik - P (PLANNING)
kolaborasi dengan dokter Sp.A - I (INSTRUKSI)
|
| 6 |
2024-04-25 11:30:12 |
Dokter Spesialis |
dr. Nur Zahara Sp.A |
- S (SUBJECTIVE)
mencret(+),demam(-) - O (OBJECTIVE)
HR:149x/i
RR:44x/i
T :37C
BB:5,2 kg
sens:cm - A (ANALYST)
GE DGN DRS - P (PLANNING)
Terapi diteruskan - I (INSTRUKSI)
|
| 7 |
2024-04-25 18:30:03 |
Perawat |
YUNI ASRI SUNARING DYAH |
- S (SUBJECTIVE)
demam(-),mencret(+) - O (OBJECTIVE)
HR:149x/i
RR:44x/i
T :37C
BB:5,2 kg - A (ANALYST)
gangguan mobilitas fisik - P (PLANNING)
kolaborasi dengan dokter Sp.A - I (INSTRUKSI)
|
| 8 |
2024-04-25 18:30:07 |
Perawat |
YUNI ASRI SUNARING DYAH |
- S (SUBJECTIVE)
demam(-),mencret berkurang - O (OBJECTIVE)
HR:149 x/i
RR:44x/i
T :37C
BB:5,2 kg - A (ANALYST)
gangguan mobilitas fisik - P (PLANNING)
kolaborasi dengan dokter Sp.A - I (INSTRUKSI)
|
| 9 |
2024-04-26 08:30:26 |
Perawat |
NUR HAWANI |
- S (SUBJECTIVE)
demam(-),mencret(-) - O (OBJECTIVE)
HR:149x/i
RR:44x/i
T :37 C
BB:5,2 kg - A (ANALYST)
gangguan mobilitas fisik - P (PLANNING)
kolaborasi dengan dokter Sp.A - I (INSTRUKSI)
|
| 10 |
2024-04-26 11:30:30 |
Dokter Spesialis |
dr. Nur Zahara Sp.A |
- S (SUBJECTIVE)
keluhan(-) - O (OBJECTIVE)
sens:cm
BB:5,2 kg - A (ANALYST)
GE DGN DRS - P (PLANNING)
pbj
L-BIO 2x1sachet - I (INSTRUKSI)
|
