Profile Pasien

Data Visit

Diagnosa

Laboratorium

Radiologi

Obat & BMHP

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Tindakan

Alat Kesehatan

USG

Profile Pasien

Data Visit

Diagnosa

CPPT

1. 2025-02-14 14:22

   • SUBJECTIVE :

     Os dari OK tiba diruangan pukul 14.00 wib k/u Nyeri luka operasi benjolan di bokong kanan yang di rasakan sejak 1 minggu ini dan memberat 2 hari ini, nyeri(+),demam(+), muntah(-)

   • OBJECTIVE :

     TD : 100/70 mmHg

     Nadi : 86 x/mnt

     RR : 23x/mnt

     Suhu : 36 ,2 ^oC

     BB : 43 Kg

     TB : 165  cm

   • ANALYST :

     Nyeri akut

   • PLANNING :

     Infus RL 20 tetes permenit 

     Injeksi ceftriaxone 1gr/12 jam

   • INSTRUKSI :
   Perawat
2. 2025-02-14 18:14

   • SUBJECTIVE :

      Nyeri luka operasi benjolan di bokong kanan, nyeri(+),demam(+), muntah(-)

   • OBJECTIVE :

     TD : 100/70 mmHg

     Nadi : 86 x/mnt

     RR : 23x/mnt

     Suhu : 36 ,2 ^oC

     BB : 43 Kg

     TB : 165  cm

   • ANALYST :

     Nyeri akut

   • PLANNING :

     Infus RL 20 tetes permenit 

     Injeksi ceftriaxone 1gr/12 jam

     inj.keterolakj 1amp/8jam

     inj.ranitidine 1amp/12jam

     iufd metrodinazole 1fls/8jam

   • INSTRUKSI :
   Perawat
3. 2025-02-15 09:24

   • SUBJECTIVE :

      Nyeri luka operasi benjolan di bokong kanan, nyeri(+),demam(+), muntah(-)

   • OBJECTIVE :

     TD : 100/70 mmHg

     Nadi : 86 x/mnt

     RR : 23x/mnt

     Suhu : 36 ,2 ^oC

     BB : 43 Kg

     TB : 165  cm

   • ANALYST :

     Nyeri akut

   • PLANNING :

     Infus RL 20 tetes permenit 

     Injeksi ceftriaxone 1gr/12 jam

     inj.keterolakj 1amp/8jam

     inj.ranitidine 1amp/12jam

     iufd metrodinazole 1fls/8jam

   • INSTRUKSI :
   Bidan
4. 2025-02-15 12:00

   • SUBJECTIVE :

     nyeri post op berkurang

     mual -

     muntah -

     demam -

   • OBJECTIVE :

     TD : 100/70 mmHg

     Nadi : 86 x/mnt

     RR : 23x/mnt

     Suhu : 36 ,2 ^oC

     BB : 43 Kg

     TB : 165  cm

   • ANALYST :

     post op abses gluteus (s)

      

   • PLANNING :

     Infus RL 20 tetes permenit 

     Injeksi ceftriaxone 1gr/12 jam

     inj.keterolakj 1amp/8jam

     inj.ranitidine 1amp/12jam

     iufd metrodinazole 1fls/8jam

   • INSTRUKSI :

     gv

   Dokter Umum
5. 2025-02-15 18:18

   • SUBJECTIVE :

     nyeri post op berkurang

     mual -

     muntah -

     demam -

   • OBJECTIVE :

     TD : 100/70 mmHg

     Nadi : 86 x/mnt

     RR : 23x/mnt

     Suhu : 36 ,2 ^oC

     BB : 43 Kg

     TB : 165  cm

   • ANALYST :

     post op abses gluteus (s)

      

   • PLANNING :

     Infus RL 20 tetes permenit 

     Injeksi ceftriaxone 1gr/12 jam

     inj.keterolak1amp/8jam

     inj.ranitidine 1amp/12jam

     ivfd metrodinazole 1fls/8jam

   • INSTRUKSI :
   Perawat
6. 2025-02-16 10:25

   • SUBJECTIVE :

     nyeri post op berkurang

     mual -

     muntah -

     demam -

   • OBJECTIVE :

     TD : 100/70 mmHg

     Nadi : 86 x/mnt

     RR : 23x/mnt

     Suhu : 36 ,2 ^oC

     BB : 43 Kg

     TB : 165  cm

   • ANALYST :

     post op abses gluteus (s)

      

   • PLANNING :

     Infus RL 20 tetes permenit 

     Injeksi ceftriaxone 1gr/12 jam

     inj.keterolak1amp/8jam

     inj.ranitidine 1amp/12jam

     ivfd metrodinazole 1fls/8jam

   • INSTRUKSI :
   Perawat
7. 2025-02-16 11:29

   • SUBJECTIVE :

     Nyeri luka operasi berkurang

   • OBJECTIVE :

     Sen : cm

     Td : 120/70

     Hr : 72

     Rr : 19

     T : 36,7

   • ANALYST :

     Post Drainase Abses a.r Gluteus

   • PLANNING :

     Teruskan Terapi

   • INSTRUKSI :
   Dokter Umum
8. 2025-02-16 18:06

   • SUBJECTIVE :

     nyeri post op berkurang

     mual -

     muntah -

     demam -

   • OBJECTIVE :

     TD : 100/70 mmHg

     Nadi : 86 x/mnt

     RR : 23x/mnt

     Suhu : 36 ,2 ^oC

     BB : 43 Kg

     TB : 165  cm

   • ANALYST :

     post op abses gluteus (s)

      

   • PLANNING :

     Infus RL 20 gtt/i

     Injeksi ceftriaxone 1gr/12 jam

     inj.keterolak1amp/8jam

     inj.ranitidine 1amp/12jam

     ivfd metrodinazole 1fls/8jam

   • INSTRUKSI :
   Perawat
9. 2025-02-17 09:12

   • SUBJECTIVE :

     nyeri post op berkurang

     mual (-)

     muntah (-)

     demam (-)

   • OBJECTIVE :

     TD : 100/70 mmHg

     Nadi : 86 x/mnt

     RR : 23x/mnt

     Suhu : 36 ,2 ^oC

     BB : 43 Kg

     TB : 165  cm

   • ANALYST :

     post op abses gluteus (s)

      

   • PLANNING :

     Infus RL 20 gtt/i

     Injeksi ceftriaxone 1gr/12 jam

     inj.keterolak1amp/8jam

     inj.ranitidine 1amp/12jam

     ivfd metrodinazole 1fls/8jam

   • INSTRUKSI :
   Perawat
10. 2025-02-17 10:30:06

    • SUBJECTIVE : Adime
    • OBJECTIVE :

      TD :100/70 mmHg

      -

      Pemenuhan kebutuhan gizi pasien berkaitan dengan penyakit yang diderita pasien  

    • ANALYST :

      Diet Makanan Biasa (MB)

    • PLANNING :

      Monitoring asupan makan pasien

      -

      Asupan makan

    • INSTRUKSI :
    Ahli Gizi
11. 2025-02-17 18:25

    • SUBJECTIVE :

      nyeri post op berkurang

      mual (-)

      muntah (-)

      demam (+)

    • OBJECTIVE :

      TD : 100/70 mmHg

      Nadi : 86 x/mnt

      RR : 23x/mnt

      Suhu : 36 ,2 ^oC

      BB : 43 Kg

      TB : 165  cm

    • ANALYST :

      nyeri akut

       

    • PLANNING :

      Infus RL 20 gtt/i

      Injeksi ceftriaxone 1gr/12 jam

      inj.keterolak1amp/8jam

      inj.ranitidine 1amp/12jam

      ivfd metrodinazole 1fls/8jam

    • INSTRUKSI :
    Perawat
12. 2025-02-17 20:08

    • SUBJECTIVE :

      nyeri bekas operasi

    • OBJECTIVE :

      luka tertutup verban

    • ANALYST :

      post debridement

    • PLANNING :

      - terapi teruskan

      - GV/ hari

    • INSTRUKSI :

      - perawatan luka

    Dokter Spesialis
13. 2025-02-18 08:47

    • SUBJECTIVE :

      nyeri post op berkurang

      mual (-)

      muntah (-)

      demam (+)

    • OBJECTIVE :

      TD : 100/70 mmHg

      Nadi : 86 x/mnt

      RR : 23x/mnt

      Suhu : 36 ,2 ^oC

      BB : 43 Kg

      TB : 165  cm

    • ANALYST :

      nyeri akut

       

    • PLANNING :

      Infus RL 20 gtt/i

      Injeksi ceftriaxone 1gr/12 jam

      inj.keterolak1amp/8jam

      inj.ranitidine 1amp/12jam

      ivfd metrodinazole 1fls/8jam

    • INSTRUKSI :

      GV/H

    Perawat
14. 2025-02-18 10:11:13

    • SUBJECTIVE : Adime
    • OBJECTIVE :

      TD : 100/70 mmHg

      T : 36,2 C

       

      -

      Pemenuhan kebutuhan gizi pasien berkaitan dengan penyakit yang diderita pasien  

    • ANALYST :

      Diet Makanan Biasa (MB)

    • PLANNING :

      Monitoring asupan makan pasien 

      -

      Asupan makan

    • INSTRUKSI :
    Ahli Gizi
15. 2025-02-18 12:23

    • SUBJECTIVE :

      Nyeri luka operasi (+) berkurang

      Luka operasi kering

      Nanah (-)

    • OBJECTIVE :

      Sen : cm

      Td : 110/70 mmHg

      Hr : 75

      Rr : 19

      T : 36,5

       

    • ANALYST :

      Post Debridement

    • PLANNING :

      PBJ

      Cefixim 2x 200 mg

      Metronidazole 3x500 mg

      Asamefenamat 3x500 mg

      Ranitidin 2x50 mg

    • INSTRUKSI :

      Kontrol ulang ke poli

    Dokter Umum
16. 2025-02-14 16:35

    • SUBJECTIVE :

      abses di bokong kanan yang di rasakan sejak 1 minggu ini dan memberat 2 hari ini

    • OBJECTIVE :

      Sens CM

      TD : 100/70 mmHg

    • ANALYST :

      Abses Gluteus Sinistra

       

    • PLANNING :

      Infus RL 20 tetes permenit 

      Injeksi ceftriaxone 1gr/12 jam

      inj.keterolakj 1amp/8jam

      inj.ranitidine 1amp/12jam

      iufd metrodinazole 1fls/8jam

    • INSTRUKSI :
    Dokter Spesialis

Laboratorium

LAB-202502175274

1. DARAH LENGKAP

   2025-02-17 15:06:35
   Lihat Hasil
2. PLASMODIUM (Malaria)

   2025-02-17 15:06:41
   Lihat Hasil

Radiologi

Obat & BMHP 2025-02-14 18:20:01 | Ringer Lactat / RL | 20 gtt/i (1fls) 2025-02-14 18:20:01 | Ketorolac inj | 1 a/8 jam (2Ampul) 2025-02-14 18:20:01 | Ranitidin inj | 1 a/12 jam (1Ampul) 2025-02-14 18:20:01 | Metronidazole infus | 1fls/8jam (2botol) 2025-02-15 09:24:25 | Ringer Lactat / RL | 20 gtt/i (2fls) 2025-02-15 09:24:25 | Ketorolac inj | 1 a/8 jam (1Ampul) 2025-02-15 09:24:25 | Ranitidin inj | 1 a/12 jam (1Ampul) 2025-02-15 09:24:25 | Metronidazole infus | 1 fls/8 jam (1botol) 2025-02-15 18:19:41 | Ringer Lactat / RL | 20 gtt/i (1fls) 2025-02-15 18:19:41 | Ceftiaxiason inj | 1gr/12jam (1Vial) 2025-02-15 18:19:41 | Ranitidin inj | 1am/12jam (1Ampul) 2025-02-15 18:19:41 | Ketorolac inj | 1a/8jam (2Ampul) 2025-02-15 18:19:41 | Metronidazole infus | 1fls/8jam (2botol) 2025-02-16 10:26:23 | Ringer Lactat / RL | 20 gtt/i (2fls) 2025-02-16 10:26:23 | Ceftiaxiason inj | 1 gr/12 jam (1Vial) 2025-02-16 10:26:23 | Ranitidin inj | 1 gr/12 jam (1Ampul) 2025-02-16 10:26:23 | Ketorolac inj | 1 a/8 jam (1Ampul) 2025-02-16 10:26:23 | Metronidazole infus | 1fls/12jam (1botol) 2025-02-16 18:08:43 | Ringer Lactat / RL | 20 gtt/i (1fls) 2025-02-16 18:08:43 | Ceftiaxiason inj | 1gr/12jam (1Vial) 2025-02-16 18:08:43 | Ranitidin inj | 1am/12jam (1Ampul) 2025-02-16 18:08:43 | Ketorolac inj | 1a/8jam (2Ampul) 2025-02-16 18:08:43 | Metronidazole infus | 1fls/8jam (2botol) 2025-02-17 09:13:45 | Ringer Lactat / RL | 20 gtt/i (1fls) 2025-02-17 09:13:45 | Ceftiaxiason inj | 1 gr/12 jam (1Vial) 2025-02-17 09:13:45 | Ranitidin inj | 1 a/12 jam (1Ampul) 2025-02-17 09:13:45 | Ketorolac inj | 1 a/8 jam (1Ampul) 2025-02-17 09:13:45 | Metronidazole infus | 1 fls/8 jam (1botol) 2025-02-17 18:26:09 | Ringer Lactat / RL | 1 (1fls) 2025-02-17 18:26:09 | Metronidazole infus | 1fls/8jam (2botol) 2025-02-17 18:26:09 | Ceftiaxiason inj | 1gr/12jam (1Vial) 2025-02-17 18:26:09 | Ranitidin inj | 1am/12jam (1Ampul) 2025-02-17 18:26:09 | Ketorolac inj | 1a/8jam (2Ampul) 2025-02-17 18:26:09 | Metronidazole infus | 1fls/8jam (2botol) 2025-02-18 08:49:01 | Ringer Lactat / RL | 20 gtt/i (2fls) 2025-02-18 08:49:01 | Ceftiaxiason inj | 1 gr/12 jam (1Vial) 2025-02-18 08:49:01 | Ranitidin inj | 1 a/12 jam (1Ampul) 2025-02-18 08:49:01 | Ketorolac inj | 1 a/8 jam (1Ampul) 2025-02-18 08:49:01 | Metronidazole infus | 1fls/8jam (1botol) 2025-02-18 12:22:54 | Cefixime Trihydrate 100mg | 2x100 mg (14Pcs) 2025-02-18 12:22:54 | Metronidazole 500 mg | 3x500mg (20tablet) 2025-02-18 12:22:54 | Ranitidin HCl 150 mg | 2x1 (14Pcs) 2025-02-18 12:22:54 | Asam Mefenamat 500mg | 3x500mg (20Pcs)

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2025-02-15 09:26:31 | Alat suntik sekali pakai spuit 10 cc | 1 (1pcs) 2025-02-15 09:26:31 | Alat suntik sekali pakai spuit 3 cc | 2 (2pcs) 2025-02-15 18:23:22 | Alat suntik sekali pakai spuit 10 cc | 1 (1pcs) 2025-02-15 18:23:22 | Alat suntik sekali pakai spuit 3 cc | 1 (2pcs) 2025-02-16 10:29:32 | Alat suntik sekali pakai spuit 10 cc | 1 (1pcs) 2025-02-16 10:29:32 | Alat suntik sekali pakai spuit 3 cc | 2 (2pcs) 2025-02-16 18:10:49 | Alat suntik sekali pakai spuit 10 cc | 1 (1pcs) 2025-02-16 18:10:49 | Alat suntik sekali pakai spuit 3 cc | 1 (2pcs) 2025-02-17 09:29:19 | Alat suntik sekali pakai spuit 10 cc | 1 (1pcs) 2025-02-17 09:29:19 | Alat suntik sekali pakai spuit 3 cc | 2 (2pcs) 2025-02-17 18:28:36 | Alat suntik sekali pakai spuit 10 cc | 1 (1pcs) 2025-02-17 18:28:36 | Alat suntik sekali pakai spuit 3 cc | 1 (2pcs) 2025-02-17 18:28:36 | Handscoen non steril (size M) | 1 (1pcs) 2025-02-18 08:51:15 | Alat suntik sekali pakai spuit 10 cc | 1 (1pcs) 2025-02-18 08:51:15 | Alat suntik sekali pakai spuit 3 cc | 2 (2pcs)

Tindakan

Alat Kesehatan

USG

Profile Pasien

Data Visit

Diagnosa

Laboratorium

Radiologi

Obat & BMHP 2025-02-14 11:53:09 | Asering | 20gtt/i (1fls) 2025-02-14 11:53:09 | Ceftiaxiason inj | 1000mg/12jam (1Vial)

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2025-02-14 11:53:37 | Handscoen non steril (size M) | 6 (6pcs) 2025-02-14 11:53:37 | Alkohol Swab | 10 (10box) 2025-02-14 11:53:37 | Blood Transfusion Set | 1 (1pcs) 2025-02-14 11:53:37 | abocath/ IV Catheter No.22 | 1 (1pcs) 2025-02-14 11:53:37 | Alat suntik sekali pakai spuit 1 cc | 1 (1pcs) 2025-02-14 11:53:37 | Alat suntik sekali pakai spuit 10 cc | 1 (1pcs)

Tindakan Pasang Infus : dr. DAMERYA PURBA Honor Dokter IGD : dr. DAMERYA PURBA

Alat Kesehatan

USG