20090112 Cmbm Status Lengkap Obgin, Rspad, Jje
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RSPAD GATOT SOEBROTO DITKESAD DEPARTEMEN OBSTETRI DAN GINEKOLOGI
CATATAN MEDIK BERORIENTASI MASALAH
STATUS PASIEN OBSTETRI GINEKOLOGI
....................................................................................................... (nama pasien dan suami)
RAHASIA
TAHUN : 2008 / 2009 / 2010 / 2011 / 2012 / 2013 / 2014 / 2015 ..................
HARAP DIBAWA SETIAP KALI PERIKSA
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
DAFTAR MASALAH TETAP Nama Pasien : ........................................................ NO
KLASIFIKASI MASALAH (DIAGNOSIS KASUS)
CMBM – JJE 20081225
TANGGAL MULAI TERJADI
Nomor CM : ............................................ TANGGAL MASALAH SELESAI
RINGKASAN PENATALAKSANAAN NAMA PPDS & DPJP
2
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
STATUS REKAM MEDIK (CMBM) PASIEN OBSTETRI GINEKOLOGI IDENTITAS PASIEN
No. CM :.................
Diisi oleh : ......................................................
Tanggal : ..................... Jam : ..........................
ISTRI :
SUAMI :
Nama
:..................................... ......
Nama
:................................................
Umur
:..................................... ......
Umur
:................................................
Pendidikan
:............................................
Pendidikan
:................................................
Pangkat
:............................................
Pangkat
:................................................
Pekerjaan
:..................................... ......
Pekerjaan
:................................................
Suku
:…………………………. ......
Suku
:…………………………….........
Agama
:…………………………. ......
Agama
:………………………………….
Gol. Darah
:…………………………. ……
Gol. Darah
:………………………………….
Alamat Rumah : …………………………………………………………………………………………… Nomor Telepon : ………………………………
No. HP : ……………………………………………
DATA DASAR Keluhan Utama ........................................................................................................................................................... Keluhan Tambahan ………………………………………………………………………………………………………………… Riwayat Penyakit Sekarang ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Perangai Pasien ………………………………………………………………………………………………………………… Riwayat Haid ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Riwayat KB ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Riwayat Pernikahan ………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………
CMBM – JJE 20081225
3
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410 Riwayat Obstetri 1. …………………………………………………………………………………………............................ 2. …………………………………………………………………………………………............................ 3. …………………………………………………………………………………………............................ 4. …………………………………………………………………………………………............................ 5. …………………………………………………………………………………………............................ 6. …………………………………………………………………………………………............................ Riwayat Penyakit Dahulu ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Riwayat Penyakit Keluarga ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ……………………………………… Catatan Penting Selama Asuhan Antenatal ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... PEMERIKSAAN FISIK Diperiksa oleh : …………………………….......
Tanggal :....................
Jam :.............................
Status Generalis Keadaan Umum : ...........................................
Kesadaran : .........................................................
Tinggi Badan
Berat Badan : …………................................. kg
: ..........................……cm
Tekanan Darah : ................................ mmHg o
Suhu Tubuh : ............................................. C
Nadi : ......................x/menit, teratur/tidak teratur Pernafasan : ................x/menit,teratur/tidak
........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ...........................................................................................................................................................
CMBM – JJE 20081225
4
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410 Status Obstetri / Ginekologi 1. Periksa Luar : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... 2. Inspekulo : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... 3. Periksa Dalam : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... Pelvimetri Klinik ( khusus ibu hamil / melahirkan ): ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ...........................................................................................................................................................
CMBM – JJE 20081225
5
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410 PEMERIKSAAN PENUNJANG DIAGNOSTIK (berisi data pemeriksaan penunjang diagnostik yang sudah dimiliki pasien sebelum pemeriksaan saat ini dilakukan) ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... DIAGNOSIS KERJA IBU : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... .......................................................................................................................................................... JANIN : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... PROGNOSIS IBU
:
........................................................................................................................................................... ........................................................................................................................................................... JANIN : ........................................................................................................................................................... ...........................................................................................................................................................
CMBM – JJE 20081225
6
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410 PENATALAKSANAAN AWAL Rencana Diagnostik : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... Rencana Terapi : ………………………………………………………………………………………………………………… .......…………………………………………………………………………………………………………… ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................………………………... …………………………………………………………………………………………………………………
Rencana Pendidikan : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... PPDS : ........................................................
DPJP : ................................................................
Tanda tangan : ....................................... ....
Tanda tangan : ....................................................
CMBM – JJE 20081225
7
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
DATA PENTING LAINNYA Nama Pasien : …………………………………. …… TGL, JAM, PEMERIKSA
Nomor CM : ……………………………...
DATA PENTING LAIN YANG TERKAIT DENGAN PENATALAKSANAAN PASIEN
TANDA TANGAN
Data yang ditulis mencakup hal penting yang dapat mempengaruhi penatalaksanaan pasien.
CMBM – JJE 20081225
8
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
PENATALAKSANAAN LANJUTAN ( S.O.A.P.) Nama Pasien : ........................................................ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
TEMUAN KLINIS DAN PENATALAKSANAAN (ditulis runut sesuai SOAP, dimengerti, tidak dicoret/dihapus)
CMBM – JJE 20081225
TANDA TANGAN
9
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
PENATALAKSANAAN LANJUTAN ( S.O.A.P.) Nama Pasien : ........................................................ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
TEMUAN KLINIS DAN PENATALAKSANAAN (ditulis runut sesuai SOAP, dimengerti, tidak dicoret/dihapus)
CMBM – JJE 20081225
TANDA TANGAN
10
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
PENATALAKSANAAN LANJUTAN ( S.O.A.P.) Nama Pasien : ........................................................ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
TEMUAN KLINIS DAN PENATALAKSANAAN (ditulis runut sesuai SOAP, dimengerti, tidak dicoret/dihapus)
CMBM – JJE 20081225
TANDA TANGAN
11
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
PENATALAKSANAAN LANJUTAN ( S.O.A.P.) Nama Pasien : ........................................................ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
TEMUAN KLINIS DAN PENATALAKSANAAN (ditulis runut sesuai SOAP, dimengerti, tidak dicoret/dihapus)
CMBM – JJE 20081225
TANDA TANGAN
12
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
PENATALAKSANAAN LANJUTAN ( S.O.A.P.) Nama Pasien : ........................................................ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
TEMUAN KLINIS DAN PENATALAKSANAAN (ditulis runut sesuai SOAP, dimengerti, tidak dicoret/dihapus)
CMBM – JJE 20081225
TANDA TANGAN
13
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
PENATALAKSANAAN LANJUTAN ( S.O.A.P.) Nama Pasien : ........................................................ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
TEMUAN KLINIS DAN PENATALAKSANAAN (ditulis runut sesuai SOAP, dimengerti, tidak dicoret/dihapus)
TANDA TANGAN
SOAP ini dilanjutkan pada lembar pengamatan lanjut TAMBAHAN
CMBM – JJE 20081225
14
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
RINGKASAN HASIL PEMERIKSAAN PENUNJANG Nama Pasien : ................................................. ........ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
HASIL PEMERIKSAAN PENUNJANG (tulis secara ringkas hasil pemeriksaan USG, CTG, dll)
CMBM – JJE 20081225
TANDA TANGAN
15
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
RINGKASAN HASIL KONSULTASI ANTAR DEPARTEMEN / DIVISI Nama Pasien : ………………………………………… TGL, JAM, PEMERIKSA
CMBM – JJE 20081225
Nomor CM : ……………………..............
HASIL KONSULTASI (tulis secara ringkas, dimengerti dan runut)
TANDA TANGAN
16
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
RINGKASAN PERSETUJUAN TINDAK MEDIK Nama Pasien : ……………………………………....... TGL, JAM, PEMERIKSA
Nomor CM : ..........................................
PERSETUJUAN TINDAK MEDIK (tulis secara ringkas, dimengerti, mencakup hal penting)
CMBM – JJE 20081225
TANDA TANGAN
17
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
SALINAN (COPY) RESEP DOKTER Nama Pasien : ……………………………………….. TGL, JAM, PEMERIKSA
Nomor CM : ………………………………
URAIAN ISI RESEP DOKTER (mencakup nama, dosis, cara dan catatan penting obat)
CMBM – JJE 20081225
TANDA TANGAN
18
CATATAN MEDIK BERORIENTASI MASALAH
STATUS PASIEN OBSTETRI GINEKOLOGI
....................................................................................................... (nama pasien dan suami)
RAHASIA
TAHUN : 2008 / 2009 / 2010 / 2011 / 2012 / 2013 / 2014 / 2015 ..................
HARAP DIBAWA SETIAP KALI PERIKSA
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
DAFTAR MASALAH TETAP Nama Pasien : ........................................................ NO
KLASIFIKASI MASALAH (DIAGNOSIS KASUS)
CMBM – JJE 20081225
TANGGAL MULAI TERJADI
Nomor CM : ............................................ TANGGAL MASALAH SELESAI
RINGKASAN PENATALAKSANAAN NAMA PPDS & DPJP
2
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
STATUS REKAM MEDIK (CMBM) PASIEN OBSTETRI GINEKOLOGI IDENTITAS PASIEN
No. CM :.................
Diisi oleh : ......................................................
Tanggal : ..................... Jam : ..........................
ISTRI :
SUAMI :
Nama
:..................................... ......
Nama
:................................................
Umur
:..................................... ......
Umur
:................................................
Pendidikan
:............................................
Pendidikan
:................................................
Pangkat
:............................................
Pangkat
:................................................
Pekerjaan
:..................................... ......
Pekerjaan
:................................................
Suku
:…………………………. ......
Suku
:…………………………….........
Agama
:…………………………. ......
Agama
:………………………………….
Gol. Darah
:…………………………. ……
Gol. Darah
:………………………………….
Alamat Rumah : …………………………………………………………………………………………… Nomor Telepon : ………………………………
No. HP : ……………………………………………
DATA DASAR Keluhan Utama ........................................................................................................................................................... Keluhan Tambahan ………………………………………………………………………………………………………………… Riwayat Penyakit Sekarang ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Perangai Pasien ………………………………………………………………………………………………………………… Riwayat Haid ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Riwayat KB ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Riwayat Pernikahan ………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………
CMBM – JJE 20081225
3
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410 Riwayat Obstetri 1. …………………………………………………………………………………………............................ 2. …………………………………………………………………………………………............................ 3. …………………………………………………………………………………………............................ 4. …………………………………………………………………………………………............................ 5. …………………………………………………………………………………………............................ 6. …………………………………………………………………………………………............................ Riwayat Penyakit Dahulu ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Riwayat Penyakit Keluarga ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ……………………………………… Catatan Penting Selama Asuhan Antenatal ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... PEMERIKSAAN FISIK Diperiksa oleh : …………………………….......
Tanggal :....................
Jam :.............................
Status Generalis Keadaan Umum : ...........................................
Kesadaran : .........................................................
Tinggi Badan
Berat Badan : …………................................. kg
: ..........................……cm
Tekanan Darah : ................................ mmHg o
Suhu Tubuh : ............................................. C
Nadi : ......................x/menit, teratur/tidak teratur Pernafasan : ................x/menit,teratur/tidak
........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ...........................................................................................................................................................
CMBM – JJE 20081225
4
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410 Status Obstetri / Ginekologi 1. Periksa Luar : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... 2. Inspekulo : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... 3. Periksa Dalam : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... Pelvimetri Klinik ( khusus ibu hamil / melahirkan ): ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ...........................................................................................................................................................
CMBM – JJE 20081225
5
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410 PEMERIKSAAN PENUNJANG DIAGNOSTIK (berisi data pemeriksaan penunjang diagnostik yang sudah dimiliki pasien sebelum pemeriksaan saat ini dilakukan) ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... DIAGNOSIS KERJA IBU : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... .......................................................................................................................................................... JANIN : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... PROGNOSIS IBU
:
........................................................................................................................................................... ........................................................................................................................................................... JANIN : ........................................................................................................................................................... ...........................................................................................................................................................
CMBM – JJE 20081225
6
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410 PENATALAKSANAAN AWAL Rencana Diagnostik : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... Rencana Terapi : ………………………………………………………………………………………………………………… .......…………………………………………………………………………………………………………… ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................………………………... …………………………………………………………………………………………………………………
Rencana Pendidikan : ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... PPDS : ........................................................
DPJP : ................................................................
Tanda tangan : ....................................... ....
Tanda tangan : ....................................................
CMBM – JJE 20081225
7
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
DATA PENTING LAINNYA Nama Pasien : …………………………………. …… TGL, JAM, PEMERIKSA
Nomor CM : ……………………………...
DATA PENTING LAIN YANG TERKAIT DENGAN PENATALAKSANAAN PASIEN
TANDA TANGAN
Data yang ditulis mencakup hal penting yang dapat mempengaruhi penatalaksanaan pasien.
CMBM – JJE 20081225
8
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
PENATALAKSANAAN LANJUTAN ( S.O.A.P.) Nama Pasien : ........................................................ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
TEMUAN KLINIS DAN PENATALAKSANAAN (ditulis runut sesuai SOAP, dimengerti, tidak dicoret/dihapus)
CMBM – JJE 20081225
TANDA TANGAN
9
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
PENATALAKSANAAN LANJUTAN ( S.O.A.P.) Nama Pasien : ........................................................ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
TEMUAN KLINIS DAN PENATALAKSANAAN (ditulis runut sesuai SOAP, dimengerti, tidak dicoret/dihapus)
CMBM – JJE 20081225
TANDA TANGAN
10
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
PENATALAKSANAAN LANJUTAN ( S.O.A.P.) Nama Pasien : ........................................................ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
TEMUAN KLINIS DAN PENATALAKSANAAN (ditulis runut sesuai SOAP, dimengerti, tidak dicoret/dihapus)
CMBM – JJE 20081225
TANDA TANGAN
11
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
PENATALAKSANAAN LANJUTAN ( S.O.A.P.) Nama Pasien : ........................................................ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
TEMUAN KLINIS DAN PENATALAKSANAAN (ditulis runut sesuai SOAP, dimengerti, tidak dicoret/dihapus)
CMBM – JJE 20081225
TANDA TANGAN
12
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
PENATALAKSANAAN LANJUTAN ( S.O.A.P.) Nama Pasien : ........................................................ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
TEMUAN KLINIS DAN PENATALAKSANAAN (ditulis runut sesuai SOAP, dimengerti, tidak dicoret/dihapus)
CMBM – JJE 20081225
TANDA TANGAN
13
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
PENATALAKSANAAN LANJUTAN ( S.O.A.P.) Nama Pasien : ........................................................ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
TEMUAN KLINIS DAN PENATALAKSANAAN (ditulis runut sesuai SOAP, dimengerti, tidak dicoret/dihapus)
TANDA TANGAN
SOAP ini dilanjutkan pada lembar pengamatan lanjut TAMBAHAN
CMBM – JJE 20081225
14
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
RINGKASAN HASIL PEMERIKSAAN PENUNJANG Nama Pasien : ................................................. ........ TGL, JAM, PEMERIKSA
Nomor CM : ............................................
HASIL PEMERIKSAAN PENUNJANG (tulis secara ringkas hasil pemeriksaan USG, CTG, dll)
CMBM – JJE 20081225
TANDA TANGAN
15
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
RINGKASAN HASIL KONSULTASI ANTAR DEPARTEMEN / DIVISI Nama Pasien : ………………………………………… TGL, JAM, PEMERIKSA
CMBM – JJE 20081225
Nomor CM : ……………………..............
HASIL KONSULTASI (tulis secara ringkas, dimengerti dan runut)
TANDA TANGAN
16
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
RINGKASAN PERSETUJUAN TINDAK MEDIK Nama Pasien : ……………………………………....... TGL, JAM, PEMERIKSA
Nomor CM : ..........................................
PERSETUJUAN TINDAK MEDIK (tulis secara ringkas, dimengerti, mencakup hal penting)
CMBM – JJE 20081225
TANDA TANGAN
17
RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410
SALINAN (COPY) RESEP DOKTER Nama Pasien : ……………………………………….. TGL, JAM, PEMERIKSA
Nomor CM : ………………………………
URAIAN ISI RESEP DOKTER (mencakup nama, dosis, cara dan catatan penting obat)
CMBM – JJE 20081225
TANDA TANGAN
18
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