Riwayat Pasien

  2. Registrasi Awal
  3. Riwayat Pasien
...
Tanggal Visit No.Pendaftaran Poliklinik Jaminan Usia Dokter Diagnosa Sumber Actions
1 2025-02-15 11:39:02 OK-20250215214 OK BPJS Kesehatan 63 tahun 7 bulan 20 hari dr. SUMRAHADI MANURUNG, Sp. B
RI
2 2025-02-14 16:04:03 RI-20250214316 RI BPJS Kesehatan 63 tahun 7 bulan 19 hari dr. SUMRAHADI MANURUNG, Sp. B
RI
  • INSTRUKSI :
    • Perawat
  • 2025-02-17 10:26:51
    • SUBJECTIVE : Adime
    • OBJECTIVE :

      TD :120/90 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
  • 2025-02-17 17:47
    • SUBJECTIVE :

      Os mengatakan demam berkurang,nyeri bekas debridement (+) di jari kaki kanan

    • OBJECTIVE :

      Os tampak  kesakitan

      TD : 130/90 mmhg

      HR :80 x/i

      RR : 21 x/i

      T : 36,7

    • ANALYST :

      Gangguan mobilitas fisik b/d nyeri

    • PLANNING :

      Ivfd Asering 20 tts/i

      Inj.Ranitidin 50 mg /12 jam

      Inj.Ketorolak 1 a/8 jam

      Inj.Ceftriaxon 1gr /12 jam

      Drip Pct 1 fls /8 jam

    • INSTRUKSI :
    Perawat
  • 2025-02-17 20:02
    • SUBJECTIVE :

      nyeri bekas operasi

    • OBJECTIVE :

      luka tertutup verban

    • ANALYST :

      post debridement

    • PLANNING :

      - Terapi teruskan

    • INSTRUKSI :

      - GV/ hari

    Dokter Spesialis
  • 2025-02-18 08:48
    • SUBJECTIVE :

      Os mengatakan demam berkurang,

      nyeri bekas debridement (+) di jari kaki kanan

    • OBJECTIVE :

      Os tampak tenang

      TD : 120/90 mmhg

      HR :80 x/i

      RR : 21 x/i

      T : 36,5

    • ANALYST :

      Gangguan pola aktivitas b/d debridemen di jari kaki kanan

    • PLANNING :

      Ivfd Asering 20 tts/i

      Inj.Ranitidin 50 mg /12 jam

      Inj.Ketorolak 1 a/8 jam

      Inj.Ceftriaxon 1gr /12 jam

      Drip Pct 1 fls /8 jam

    • INSTRUKSI :
    Perawat
  • 2025-02-18 10:02:11
    • SUBJECTIVE : Adime
    • OBJECTIVE :

      TD :120/90 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
  • 2025-02-18 10:46
    • SUBJECTIVE :

      Nyeri luka operasi (+) berkurang

      Luka operasi kecil

       

    • OBJECTIVE :

      Sen : cm

      Td : 110/80 mmHg

      Hr : 76

      Rr : 19

      T : 36,8

       

    • ANALYST :

      Post Debridement 

       

    • PLANNING :

      PBJ

      Cefixim 2x200 mg

      Metronidazole 3x500 mg

      Asamefenamat 3x500 mg

      Ranitidin 2x1

    • INSTRUKSI :
    Dokter Umum
    • Laboratorium
    LAB-202502178249
    1. KGD PUASA
      2025-02-17 07:04:44
      Lihat Hasil
    2. KGD 2 JAM PP
      2025-02-17 07:15:15
      Lihat Hasil
    Radiologi
    Obat & BMHP 2025-02-14 17:55:53 | Asering | 500ml (1fls) 2025-02-14 17:55:53 | Ranitidin inj | 1a/12jam (1Ampul) 2025-02-14 17:55:53 | Ketorolac inj | 1a/12jam (1Ampul) 2025-02-14 17:55:53 | Ceftiaxiason inj | 1gram/12jam (1Vial) 2025-02-14 17:55:53 | Paracetamol infus/ drip | 1fls/8jam (1botol) 2025-02-15 08:59:22 | Asering | fls (1fls) 2025-02-15 08:59:22 | Ranitidin inj | 1a/12jam (1Ampul) 2025-02-15 08:59:22 | Ketorolac inj | 1a/8jam (1Ampul) 2025-02-15 08:59:22 | Paracetamol infus/ drip | 1fls/8jam (1botol) 2025-02-15 08:59:22 | Ceftiaxiason inj | 1gram/12jam (1Vial) 2025-02-15 08:59:22 | Asering | 500ml (1fls) 2025-02-15 08:59:22 | Ketorolac inj | 1a/8jam (1Ampul) 2025-02-15 08:59:22 | Ranitidin inj | 1a/12jam (1Ampul) 2025-02-15 08:59:22 | Paracetamol infus/ drip | 1fls/8jam (2botol) 2025-02-16 08:36:02 | Asering | 20tts/i (1fls) 2025-02-16 08:36:02 | Paracetamol infus/ drip | 1fls/8jam (1botol) 2025-02-16 17:26:15 | Asering | fls (1fls) 2025-02-16 17:26:15 | Ranitidin inj | 1gram/12jam (1Ampul) 2025-02-16 17:26:15 | Ceftiaxiason inj | 1gram/12jam (1Vial) 2025-02-16 17:26:15 | Ketorolac inj | 1a/8jam (2Ampul) 2025-02-16 17:26:15 | Paracetamol infus/ drip | 1fls/8jam (2botol) 2025-02-17 08:22:39 | Asering | fls (1fls) 2025-02-17 08:22:39 | Ranitidin inj | 1a/12jam (1Ampul) 2025-02-17 08:22:39 | Ceftiaxiason inj | 1gram/12jam (1Vial) 2025-02-17 08:22:39 | Ketorolac inj | 1a/8jam (1Ampul) 2025-02-17 08:22:39 | Paracetamol infus/ drip | 1fls/8jam (1botol) 2025-02-17 17:49:53 | Asering | 20tts/i (1fls) 2025-02-17 17:49:53 | Ceftiaxiason inj | 1gram/12jam (1Vial) 2025-02-17 17:49:53 | Ranitidin inj | 1a/12jam (1Ampul) 2025-02-17 17:49:53 | Ketorolac inj | 1a/8jam (2Ampul) 2025-02-17 17:49:53 | Paracetamol infus/ drip | 1fls/8jam (2botol) 2025-02-18 08:50:54 | Ceftiaxiason inj | 1gram/12jam (1Vial) 2025-02-18 08:50:54 | Ranitidin inj | 1a/12jam (1Ampul) 2025-02-18 08:50:54 | Ketorolac inj | 1a/8jam (1Ampul) 2025-02-18 08:50:54 | Paracetamol infus/ drip | 1fls/8jam (1botol) 2025-02-18 08:50:54 | Asering | fls (1fls) 2025-02-18 08:50:54 | Paracetamol 500 mg | 3x1 (2tablet) 2025-02-18 12:34:42 | Cefixime 200 mg | 2x200mg (14tablet) 2025-02-18 12:34:42 | Ranitidin HCl 150 mg | 3x1` (20Pcs) 2025-02-18 12:34:42 | Paracetamol 500 mg | 3x1` (20tablet) 2025-02-18 12:34:42 | Metronidazole 500 mg | 3x1` (20tablet)
    2025-02-14 17:57:11 | Alat suntik sekali pakai spuit 10 cc | 1 (1pcs) 2025-02-14 17:57:11 | Alat suntik sekali pakai spuit 3 cc | 2 (2pcs) 2025-02-15 09:01:34 | Alat suntik sekali pakai spuit 10 cc | pcs (1pcs) 2025-02-15 09:01:34 | Alat suntik sekali pakai spuit 3 cc | pcs (1pcs) 2025-02-15 09:01:34 | Alat suntik sekali pakai spuit 10 cc | 1 (1pcs) 2025-02-15 09:01:34 | Alat suntik sekali pakai spuit 3 cc | 2 (2pcs) 2025-02-16 17:32:28 | Alat suntik sekali pakai spuit 10 cc | pcs (1pcs) 2025-02-16 17:32:28 | Alat suntik sekali pakai spuit 3 cc | pcs (1pcs) 2025-02-17 08:24:20 | Alat suntik sekali pakai spuit 10 cc | pcs (1pcs) 2025-02-17 08:24:20 | Alat suntik sekali pakai spuit 3 cc | pcs (1pcs) 2025-02-17 17:53:31 | Alat suntik sekali pakai spuit 10 cc | pcs (1pcs) 2025-02-17 17:53:31 | Alat suntik sekali pakai spuit 3 cc | pcs (1pcs) 2025-02-18 08:52:48 | Alat suntik sekali pakai spuit 10 cc | pcs (1pcs) 2025-02-18 08:52:48 | Alat suntik sekali pakai spuit 3 cc | pcs (1pcs)
    Tindakan
    Alat Kesehatan
    USG
    3 2025-02-14 15:24:07 IGD-20250214316 IGD BPJS Kesehatan 63 tahun 7 bulan 19 hari dr. DAMERYA PURBA
    • L02.0 | Cutaneous abscess, furuncle and carbuncle of face Primer
    IGD
    Tanggal Rencana Kontrol No.Pendaftaran Catatan Status
    2025-02-25 RI-20250214316 kontrol ulang Belum Kontrol