Profile Pasien

Data Visit

Diagnosa

CPPT

1. 2025-01-25 03:05

   • SUBJECTIVE :

     Os tiba di VK dari ruang OK pukul 01.15 wib dalam keadaan sadar, nyeri bekas luka operasi (+), demam (-), mual (-), muntah (-), perdarahan (-)

   • OBJECTIVE :

     TD: 100/70 mmhg

     HR: 84 x/i

     RR: 20 x/i

     T:36,5 c

   • ANALYST :

     P2A0 post sc a/i Previous sc 1x

   • PLANNING :

     Terapi:

     -IVFD RL 20 gtt/i

     -Inj Ceftriaxone 1gr/12 jam

     -Inj, Ranitidin 1amp/8 jam

     -Inj Ketorolac 1amp/8 jam

     -Inj Asam Tranexamat 500mg/12 jam

     -Metronidazole drip 1fls/8jam

   • INSTRUKSI :

     -Pantau TTV pasien

   Bidan
2. 2025-01-25 08:15

   • SUBJECTIVE :

     Telah lahir seorang bayi laki2 secara sc pukul 00.05 wib, langsung menangis kuat (+)

     Gerak aktif (+),  kulit kemerahan (+)

   • OBJECTIVE :

     JK : Laki2

     Anus : +

     A/s : 7/8.                                                 LD : 34 cm

     BB : 2500gr                                             LK : 33cm

     HR : 144 x /i                                            PB : 49cm

     RR : 42 x /i                                               T   : 36c

      

   • ANALYST :

     Ncb  + smk

   • PLANNING :

     Konsultasi via tlfn dr. Omar Sp. A

     Perawatan tali pusat 

     Inj. Vit k

     Inj. Hb0

     Gentamisin salap mata

     ASI / PASI 15-20 cc/3jam

   • INSTRUKSI :
   Dokter Umum
3. 2025-01-25 15:00

   • SUBJECTIVE :

     S:Os mengatakan nyeri luka operasi (+),mual (-),muntah (-),demam (-),perdarahan (-)

   • OBJECTIVE :

     TD:100/70 mmhg

     HR:78 x/i

     RR:20 x/i

     T:36 C

   • ANALYST :

     P2A0 post SC a/i prev SC 1 x

   • PLANNING :

     - Pantau TTV

     - Berikan therapy sesuai advice dokter

     -IVFD RL 20 gtt/i

     -inj.ceftriaxone 1gr/12 jam

     -inj.ketorolac 1 a/8 jam

     -inj.ranitidin 1/8 jam

     inj.As.tranexamat 500 mg/8 jam

     -metronidazole drip 1fls/8 jam

      

   • INSTRUKSI :

     pantau ttv

   Bidan
4. 2025-01-25 13:01

   • SUBJECTIVE :

     -

   • OBJECTIVE :

     TD :120 / 80 MmHg 

     Abd : soepel peristaltik

     P /L : (+) lochea

   • ANALYST :

     post sc + previus sc

   • PLANNING :

     therapy lanjutkan

     aff kateter pukul 00:00 wib

   • INSTRUKSI :
   Dokter Spesialis
5. 2025-01-25 23:45

   • SUBJECTIVE :

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

   • OBJECTIVE :

     Td; 100/ 80

     Rr: 20X/i

     Hr; 80Xi

     Temp; 36,5 c

   • ANALYST :

     P2AO post sc a/i prev sc 1x

   • PLANNING :

     Pantau TTV px

     berikan therapy sesuai advice dokter

     therapy;-iufd rl asering 20tts/i

                 -ceftriaxone 1gr/12 jam

                 -iufd metronidazol 1 fls/8jam

                 -inj A.tranexamat 500mg/12jam

                 -inj keterolac 1A/8jam

                 -inj ranitidine 1A/8jam

   • INSTRUKSI :
   Perawat
6. 2025-01-26 15:00

   • SUBJECTIVE :

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

   • OBJECTIVE :

     TD:100/80 MMHG

     HR:78 x/i

     RR:20 x/i

     T:36,5 C

   • ANALYST :

     P2A0 POST SC a/i prev SC 1x

   • PLANNING :

     -Anjurkan ibu untuk mobilisasi dini

     - Therapy lanjut

     -IVFD asering 20 gtt/i

     -Ceftriaxone 1gr/12 jam

     -metronidazol 3x1

     -asam mefenamat 3x1

     -TTD 2x1

   • INSTRUKSI :

     Pantau TTV

   Bidan
7. 2025-01-25 12:31

   • SUBJECTIVE :

      nyeri  luka operasi (+), demam (-),perdarahan  (-)

   • OBJECTIVE :

     TD:100/80 MMHG

     HR:78 x/i

     RR:20 x/i

     T:36,5 C

   • ANALYST :

     P2A0 POST SC a/i prev SC 1x

   • PLANNING :

     -IVFD asering 20 gtt/i

     -Ceftriaxone 1gr/12 jam

     -metronidazol 3x1

     -asam mefenamat 3x1

     -TTD 2x1

   • INSTRUKSI :

     konsul via telpn dengan dr rizal spog 

     mobilisasi kanan kiri dan duduk

     katrofen supp 1x extra

   Dokter Umum
8. 2025-01-26 12:33

   • SUBJECTIVE :

      nyeri  luka operasi (+), demam (-),perdarahan  (-)

   • OBJECTIVE :

     TD:100/80 MMHG

     HR:78 x/i

     RR:20 x/i

     T:36,5 C

   • ANALYST :

     P2A0 POST SC a/i prev SC 1x

   • PLANNING :

     -IVFD asering 20 gtt/i

     -Ceftriaxone 1gr/12 jam

     -metronidazol 3x1

     -asam mefenamat 3x1

     -TTD 2x1

   • INSTRUKSI :

     konsul via telpn dengan dr rizal spog 

     mobilisasi kanan kiri dan duduk

     aff kateter 

     aff infus nanti malam

     rencana pbj besok pagi

     obat pbj

     cefadroxyl 2x500mg

     as mefenamat 3x500mg

     metronidazol 3x500mg

     ttd 2x1

     vit c 2x1

   Dokter Umum
9. 2025-01-26 10:01

   • SUBJECTIVE :

     -

   • OBJECTIVE :

     TD : 110 / 80 MmHg

     Abd : soepol peristaltik

     p /L : (+) lochea

      

   • ANALYST :

     post sc + previus sc

   • PLANNING :

     therapy lanjutkan

     aff infus

   • INSTRUKSI :
   Dokter Spesialis
10. 2025-01-26 21:29

    • SUBJECTIVE :

      os mengatakan nyeri luka operasi (+) mual muntah(-) perdarahan(-) pusing (-)

    • OBJECTIVE :

      Td; 100/80

      Hr; 80x/i

      Rr; 20x/i

      Temp;36,3 c

    • ANALYST :

      P2AO post sc a/i prev sc 1x

    • PLANNING :

      pantau TTV pasien

      Berikan therapy sesuai advice dokter

      o/oral ;

      cefadroxil 2x1

      asmet 3x1

      Tablet tambah darah 2x1

      metronidazol tab 3x1

       

    • INSTRUKSI :
    Perawat
11. 2025-01-27 10:25

    • SUBJECTIVE :

       nyeri  luka operasi (+) berkurang

       demam (-),perdarahan  (-)

      Keluhan lain (-)

    • OBJECTIVE :

      TD:120/80 MMHG

      HR:78 x/i

      RR:20 x/i

      T:36,5 C

    • ANALYST :

      P2A0 POST SC a/i prev SC 1x

    • PLANNING :

      Pbj 

      Cefadroxil 2 x 1

      Asmef 3 x 1

      Metronidazole 3 x 500mg

      Ttd 2 x 1

      Vit c 2 x 1

    • INSTRUKSI :
    Dokter Umum
12. 2025-01-27 10:31

    • SUBJECTIVE :

      OS MENGATAKAN NYERI LUKA OPERASI(+)MUAL(-)

      PENDRAHAN(-)

    • OBJECTIVE :

      KU BAIK

      TD:120/80 MMHG

      HR:78X/I

       

    • ANALYST :

      P2A0 POST SC+PREVIUS SC 1X

    • PLANNING :

      -MEMBERIKAN THERAPY SESUAI ANJURAN DOKTER

      -RENCANA PBJ

    • INSTRUKSI :
    Bidan

Laboratorium

LAB-202501252344

1. DARAH LENGKAP

   2025-01-25 07:10:29
   Lihat Hasil

Radiologi

Obat & BMHP 2025-01-25 06:49:49 | Ranitidin inj | 1amp/8jam (1Ampul) 2025-01-25 06:49:49 | Ketorolac inj | 1amp/8jam (1Ampul) 2025-01-25 06:49:49 | Metronidazole infus | 1fls/8jam (1botol) 2025-01-25 06:49:49 | Asam Tranexamat inj | 500 mg/12 jam (1Ampul) 2025-01-25 06:49:49 | Vitamin k | - (1Tablet) 2025-01-25 06:49:49 | HB 0 Vaksin | - (1Pcs) 2025-01-25 06:49:49 | Gentamicin Slp mata 0.3% | - (1tube) 2025-01-25 06:49:49 | Asam Tranexamat inj | 500 mg/12 jam (2Ampul) 2025-01-25 06:49:49 | Metronidazole infus | 3x1 (1botol) 2025-01-25 06:49:49 | Ketorolac inj | 3x1 (1Ampul) 2025-01-25 06:49:49 | Ranitidin inj | 3x1 (1Ampul) 2025-01-25 06:49:49 | Ringer Lactat / RL | - (2fls) 2025-01-25 18:05:27 | Ceftiaxiason inj | 1gr/12jam (1Vial) 2025-01-25 18:05:27 | Metronidazole infus | 3x1 (2botol) 2025-01-25 18:05:27 | Asam Tranexamat inj | 500 mg/12 jam (1Ampul) 2025-01-25 18:05:27 | Ketorolac inj | 3x1 (2Ampul) 2025-01-25 18:05:27 | Ranitidin inj | 3x1 (2Ampul) 2025-01-26 09:36:22 | Ceftiaxiason inj | 2 X 1 (1Vial) 2025-01-26 09:36:22 | Metronidazole 500 mg | 3x1 (1tablet) 2025-01-26 09:36:22 | Tablet tambah darah | 2 X 1 (1Tablet) 2025-01-26 09:36:22 | Aqua pro injection | - (1Vial) 2025-01-26 20:35:42 | Asam Mefenamat 500mg | 3x1 (2Pcs) 2025-01-26 20:35:42 | Cefadroxil Monohydrate 500mg | 2 X 1 (2tablet) 2025-01-26 20:35:42 | Tablet tambah darah | 2 X 1 (2Tablet) 2025-01-26 20:35:42 | Metronidazole 500 mg | 3x1 (2tablet) 2025-01-27 10:18:53 | Metronidazole 500 mg | 3x1 (10tablet) 2025-01-27 10:18:53 | Asam Mefenamat 500mg | 3x1 (10Pcs) 2025-01-27 10:18:53 | Tablet tambah darah | 2 X 1 (10Tablet) 2025-01-27 10:18:53 | Cefadroxil Monohydrate 500mg | 2 X 1 (10tablet) 2025-01-27 10:18:53 | Gentamicin Salep Kulit 0,1 % | 1 (1tube)

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2025-01-25 06:54:41 | Alat suntik sekali pakai spuit 10 cc | - (1pcs) 2025-01-25 06:54:41 | Alat suntik sekali pakai spuit 3 cc | - (2pcs) 2025-01-25 06:54:41 | Selang Oxygen Bayi | - (1pcs) 2025-01-25 06:54:41 | Alat suntik sekali pakai spuit 1 cc | - (1pcs) 2025-01-25 06:54:41 | Kasa Hydrophil Steril Uk 16 cm x 16 cm | - (1box) 2025-01-25 06:54:41 | Suction Cateter no.6 | - (1pcs) 2025-01-25 06:54:41 | Alat suntik sekali pakai spuit 10 cc | - (1pcs) 2025-01-25 06:54:41 | Alat suntik sekali pakai spuit 5 cc | - (1pcs) 2025-01-25 18:22:30 | Alat suntik sekali pakai spuit 10 cc | - (1pcs) 2025-01-25 18:22:30 | Alat suntik sekali pakai spuit 3 cc | - (1pcs) 2025-01-27 10:21:24 | Handscoen Steril (size 7) | 1 (1pcs)

Tindakan

Alat Kesehatan

USG

Profile Pasien

Data Visit

Diagnosa

Laboratorium

Radiologi

Obat & BMHP

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Tindakan

Alat Kesehatan

USG

Profile Pasien

Data Visit

Diagnosa

Laboratorium

LAB-202501249745

1. DARAH LENGKAP

   2025-01-24 22:00:17
   Lihat Hasil
2. KGD AD RANDOM

   2025-01-24 22:00:22
   Lihat Hasil
3. CTBT (Masa Pembekuan Masa Pendarahan)

   2025-01-24 22:00:33
   Lihat Hasil
4. GOLONGAN DARAH

   2025-01-24 22:00:47
   Lihat Hasil
5. URINE LENGKAP

   2025-01-24 22:00:56
   Lihat Hasil

Radiologi

Obat & BMHP 2025-01-24 22:01:07 | Asering | / 8jam (1fls) 2025-01-24 22:01:07 | Ceftiaxiason inj | /12 jam (1Vial) 2025-01-24 22:01:07 | Nifedipine 10 mg | 1x10mg (1tablet) 2025-01-24 22:01:07 | Dexamethason inj | ekstra (3Ampul) 2025-01-24 22:01:07 | Hystolan (Isoxsuprine 20 mg) | ekstra (1tablet)

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2025-01-24 22:02:32 | Handscoen non steril (size M) | (4pcs) 2025-01-24 22:02:32 | Blood Transfusion Set | (1pcs) 2025-01-24 22:02:32 | abocath/ IV Catheter No.20 | (1pcs) 2025-01-24 22:02:32 | Alkohol Swab | (1box) 2025-01-24 22:02:32 | Alat suntik sekali pakai spuit 1 cc | (1pcs) 2025-01-24 22:02:32 | Alat suntik sekali pakai spuit 10 cc | (2pcs) 2025-01-24 22:02:32 | Urine Bag | (1pcs) 2025-01-24 22:02:32 | Pot urin | (1pcs) 2025-01-24 22:02:32 | Alat suntik sekali pakai spuit 5 cc | (1pcs)

Tindakan

Alat Kesehatan

USG