copy of clinical pathway rajal. dr tuty

FORMAT UMUM CLINICAL PATHWAYS

LOGO CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX1

.................................... ............ .........kg ............cm ..........................Kode ICD 10 : HOO.1,H11.0,H00.0

Aktivitas Pelayanan

R. Rawat Tgl/Jam masuk : Tgl/Jam keluar : Lama rawat : Kelas : Tarif/hr (Rp) : Biaya (Rp) :

Hari Rawat 1 Hari Rawat 2 Hari Rawat 3Hari Sakit:... Hari Sakit:... Hari Sakit:...

Diagnosis :................... ............................ .......................... ........................................... ............................ .......................... ........................................... ............................ .......................... ........................

Administrasi RM Lengkap ............................ .......................... ........................ 25.000 + 6000 31,000 Akomodasi Sewa kamar 30,000 Akomodasi lain Akmds lain-lainAssesmen Klinis :

dr.SpM 30,000

Laborat

Radiologi

* Medis Incisi, curetage,Exsisi 125,000

* Keperawatan VitalsignObservasi PasienScerent

* Obat* Obat IBS Tab amoxicilin 3x500 mg

Tab As Met 3x500 mgSalep mata KloramhenicolInj Lidocain 2 % 1 amp

* Obat pulang Tab amoxicilin 3x500 mgTab As Met 3x500 mg

BHPDi IBS Kaca steril 1 box

Plaster kecil 1 rol 6,050 Alkohol 10 cc 450 Betadine 10 ccKapas lidi 5

ALKESdi IBS Spuit 1 cc 1 3,432

Spuit 5 cc 1

Makanan Biasa

***

Pemulangan :

Jumlah Biaya 225,932 Kode ICD 10 : HOO.1,H1 Kode ICD 9 - CM

............................. * Utama * Kode INA DRG : 02230* Penyerta ............................ ............................. *

...................... ............................ ............................. *Nama Pelaksana * Komplikasi ............................ ............................. *Verifikasi : 38 ............................ ............................. *......................

SMF MATA2 RSUD RAA SOEWONDO PATI 3

EKSISI PTERIGIUM / LA Tanpa Free Flap ( Nama Penyakit )4

Tahun 2012 5

Nama Pasien : 6 Umur : 7 Berat Badan : 8 Tinggi Badan : 9 Nomor Rekam Medis : 10

Diagnosis Awal :..............................11 Rencana rawat : ..........hari 13

.....14....... .....15....... .....16....... .....17.....hari .....18....... .....19....... .....20.......

* Penyakit Utama 22

* Penyakit Penyerta 23

* Komplikasi 24

* Pemeriksaan dokter 25

* Konsultasi 26

Pemeriksaan Penunjang27

Tindakan : 28

Obat-obatan : 29

Nutrisi : 29

Mobilisasi : 30

Hasil (Outcome): 31

Pendidikan/Rencana 32

Varians : 33

Nama Perawat : 36 Diagnosis Akhir 34 Jenis Tindakan 35

Nama Dokter : 37



.................................... ............ .........kg ............cm ..........................Kode ICD 10 : HOO.1,H11.0,H00.0

Aktivitas Pelayanan


Hari Rawat 1 Hari Rawat 2 Hari Rawat 3Hari Sakit:... Hari Sakit:... Hari Sakit:...

Diagnosis :................... ............................ .......................... ........................................... ............................ .......................... ........................................... ............................ .......................... ........................

Administrasi RM Lengkap ............................ .......................... ........................ 25.000 + 6000 31,000 Akomodasi Sewa kamar 30,000 Akomodasi lain Akmds lain-lainAssesmen Klinis :

dr.SpM 30,000

Laborat

Radiologi

* Medis Incisi, curetage,Exsisi 125,000

* Keperawatan VitalsignObservasi PasienScerent

* Obat* Obat IBS Tab amoxicilin 3x500 mg

Tab As Met 3x500 mgSalep mata KloramhenicolInj Lidocain 2 % 1 amp

* Obat pulang Tab amoxicilin 3x500 mgTab As Met 3x500 mg

BHPDi IBS Kaca steril 1 box

Plaster kecil 1 rol 6,050 Alkohol 10 cc 450 Betadine 10 ccKapas lidi 5

ALKESdi IBS Spuit 1 cc 1 3,432

Spuit 5 cc 1

Makanan Biasa

***

Pemulangan :

Jumlah Biaya 225,932 Kode ICD 10 : HOO.1,H1 Kode ICD 9 - CM

............................. * Utama * Kode INA DRG : 02230* Penyerta ............................ ............................. *

...................... ............................ ............................. *Nama Pelaksana * Komplikasi ............................ ............................. *Verifikasi : 38 ............................ ............................. *......................

SMF MATA DAN THT 2 RSUD RAA SOEWONDO PATI 3

Chalazion, Pterigium, Hordeolum ( Nama Penyakit )4

Tahun 2012 5



.....14....... .....15....... .....16....... .....17.....hari .....18....... .....19....... .....20.......

* Penyakit Utama 22


* Komplikasi 24


* Konsultasi 26


Tindakan : 28

Obat-obatan : 29

Nutrisi : 29

Mobilisasi : 30

Hasil (Outcome): 31


Varians : 33


Nama Dokter : 37



.................................... ............ .........kg ............cm ..........................Kode ICD 10 : E14.9

Aktivitas Pelayanan

R. Rawat Tgl/Jam masuk Tgl/Jam keluar : Lama rawat : Kelas : Tarif/hr (Rp) : Biaya (Rp) :

Hari Rawat 1Hari Sakit:...

Diagnosis :................... ......................... ......................... ........................ ..................... ...................................... ......................... ......................... ........................ ..................... ...................................... ......................... ......................... ........................ ..................... ...................

Administrasi RM Lengkap ......................... ......................... ........................ ..................... 25000 + 6000 31,000 AkomodasiAssesmen Klinis :

dr.Sp.PD 25,000 Gizi 15,000 Edukasi DM 15,000

Laborat Urine Rutin 15,000 GDS 10,000

Radiologi

* Dokter* Keperawatan Vitalsign

Glibenklamide 1x1mg=30tab 4,500 Vit.B1 1x1=30tab

Vit.B6 1x1=30tab

Vit.B12 1x1 = 30tab

BHPALKES

* ................... ......................... ......................... ........................* ................... ......................... ......................... ........................* ................... ......................... ......................... ........................

................... ......................... ......................... ........................Pemulangan :

................... ......................... ......................... ........................

................... ......................... ......................... ........................

................... ......................... ......................... ........................

Jumlah Biaya 115,500 Kode ICD 10 Kode ICD 9 - CM

.............................. * Utama ......................... E14.9 * Kode INA DRG : 235430* Penyerta ......................... ......................... *

...................... ......................... ......................... *Nama Pelaksana * Komplikasi ......................... ......................... *Verifikasi : 38 ......................... ......................... *......................

Halaman 1

SMF P. DALAM RSUD RAA SOEWONDO PATI 3

DIABETES MELLITUS4

Tahun 2012 5

Nama Pasien : 6 Umur : 7 Berat Badan : 8 Tinggi Badan : 9Nomor Rekam Medis : 10


.....14....... .....15....... .....16....... .....17.....hari .....18....... .....19....... .....20.......

* Penyakit Utama 22


* Komplikasi 24


* Konsultasi 26


Tindakan : 28

Obat-obatan : 29

Nutrisi : 29

Mobilisasi : 30

Hasil (Outcome): 31


Varians : 33


Nama Dokter : 37



.................................... ............ .........kg ............cm ..........................

Aktivitas Pelayanan


Hari Rawat 1 Obat PulangHari Sakit:...

Diagnosis :................... ............................. .......................... ........................ .......................... ...................................... ............................. .......................... ........................ .......................... ...................................... ............................. .......................... ........................ .......................... ...................

Administrasi RM Lengkap ............................. .......................... ........................ .......................... 25.000 + 6.000 31,000 Akomodasi ................... ............................. .......................... ........................ .......................... ................... - Assesmen Klinis :

dr.Sp.S ............................. .......................... ........................ .......................... ................... 25,000 dr.Sp.RM ............................. .......................... ........................ .......................... .......................... 25,000 ................... ............................. .......................... ........................ .......................... .......................... ........................

Laborat ................... ........................ Radiologi ................... ........................

................... ............................. .......................... ........................ .......................... .......................... ..........................* Dokter* Keperawatan Vitalsign

Carbamazepin 3x1 = 21 tab

21,714

As.Mef 500mg 3x1=21tab

Vit.B1 3x1 =21tab

Vit.B6 3x1 =21tab

Vit.B12 3x1 =21tab

BHP - ALKES -

-

* ................... ............................. .......................... ........................ ..........................* ................... ............................. .......................... ........................ ..........................* ................... ............................. .......................... ........................ ..........................

................... ............................. .......................... ........................ ..........................Pemulangan :

................... ............................. .......................... ........................ ..........................

................... ............................. .......................... ........................ ..........................

................... ............................. .......................... ........................ ..........................


.............................. * Utama ............................. G59.0 * Kode INA DRG : 235440

* Penyerta ............................. ............................ *...................... ............................. ............................ *Nama Pelaksana * Komplikasi ............................. ............................ *Verifikasi : 38 ............................. ............................ *......................

Halaman 1

SMF SYARAF RSUD RAA SOEWONDO PATI 3

NEUROPHATY DIABETIC 4

Tahun 2012 5


Diagnosis Awal :..............................11 Kode ICD 10 :G59.012 Rencana rawat : 1 hari 13

.....14....... .....15....... .....16....... .....17.....hari .....18....... .....19....... .....20.......

* Penyakit Utama 22


* Komplikasi 24


* Konsultasi 26


Tindakan : 28

Obat-obatan : 29

Nutrisi : 29

Mobilisasi : 30

Hasil (Outcome): 31


Varians : 33


Nama Dokter : 37

21



.................................... ............ .........kg ............cm ..........................

Aktivitas Pelayanan


Hari Rawat 1 Hari Rawat 2 Hari Rawat 3 Hari Rawat 4 Hari Rawat 5Hari Sakit:... Hari Sakit:... Hari Sakit:... Hari Sakit:... Hari Sakit:...

Diagnosis :................... ............................. .......................... ........................ .......................... ...................................... ............................. .......................... ........................ .......................... ...................................... ............................. .......................... ........................ .......................... ...................

Administrasi RM Lengkap ............................. .......................... ........................ .......................... 25.000 + 6.000 31,000 Akomodasi ................... ............................. .......................... ........................ .......................... ................... -

................... ............................. .......................... ........................ .......................... ................... - Assesmen Klinis :

dr.Sp.B ............................. .......................... ........................ .......................... ................... 25,000 ................... ............................. .......................... ........................ .......................... .......................... - ................... ............................. .......................... ........................ .......................... .......................... ........................

Laborat Darah rutin ............................. .......................... ........................ .......................... .......................... 45,000 Radiologi ................... -

................... ............................. .......................... ........................ .......................... .......................... ..........................* Dokter Excisi 125,000 * Keperawatan Perawatan Luka ............................. .......................... ........................ .......................... ..........................

Vitalsign ............................. .......................... ........................ .......................... ..........................

Amoxicilin 3x500mg=15tab ............................. .......................... ........................ .......................... .......................... 8,750 Asmef 3x500mg =15tab ............................. .......................... ........................ .......................... ..........................

BHP Kassa 10lbr

11,175 Alkohol70%=50cc

Betadine 50cc

ALKES Handschoon 2 psg 16900

34,925

Besturi 1 buah 5294

Benang cromix 2.0 = 1/2 mtr 6700

Benang Zide 75cm 4650

Jarum jahit 1 buah 1375

................... ............................. .......................... ........................ .......................... .......................... ..........................

* ................... ............................. .......................... ........................ ..........................* ................... ............................. .......................... ........................ ..........................* ................... ............................. .......................... ........................ ..........................

................... ............................. .......................... ........................ ..........................Pemulangan :

................... ............................. .......................... ........................ ..........................

................... ............................. .......................... ........................ ..........................

................... ............................. .......................... ........................ ..........................


............................ * Utama ............................. K40.9,K41.9 * Kode INA DRG : O61.141* Penyerta ............................. ............................. *

...................... ............................. ............................. *Nama Pelaksana * Komplikasi ............................. ............................. *Verifikasi : 38 ............................. ............................. *......................

SMF BEDAH UMUM RSUD RAA SOEWONDO PATI 3

CLAVUS/ATHEROMA/LIPOMA/PAPILOMA/NEVUS/NEUROFIBROMA/ABSCESS/ 4

NAEGLE EXTRAKSI/KELOID Ǿ < 2cm/DAWIR/TINDIK/CIRCUMSISI/CATETERISASI

Tahun 2012 5


Diagnosis Awal :..............................11 Kode ICD 10 : .....................12 Rencana rawat : ..........hari 13

.....14....... .....15....... .....16....... .....17.....hari .....18....... .....19....... .....20.......

* Penyakit Utama 22


* Komplikasi 24


* Konsultasi 26


Tindakan : 28

Obat-obatan : 29

Nutrisi : 29

Mobilisasi : 30

Hasil (Outcome): 31


Varians : 33

Nama Perawat : 36Diagnosis Akhir 34 Jenis Tindakan 35

Nama Dokter : 37

2121



.................................... ............ .........kg ............cm ..........................

Aktivitas Pelayanan

R. Rawat Tgl/Jam masuTgl/Jam keluaLama rawat : Kelas : Tarif/hr (Rp) : Biaya (Rp) :

Hari Rawat 1Hari Sakit:...

Diagnosis :................... ..................... ..................... ..................... ............................................. ..................... ..................... ..................... ............................................. ..................... ..................... ..................... ..........................

Administrasi RM Lengkap ..................... ..................... ..................... ..................... 6,000 6,000 Akomodasi

Assesmen Klinis :drg 15,000

Radiologi -

* Dokter Pencabutan 200,000

* Keperawatan Suction

Oral Hygiene

Lidocain 2 amp - Obat pulang Amoxicilin 3x500mg = 10 3630

5,830 Asam Mefenamat 3x500 = 10 2200

BHP Kapas 10gr

2250

7,875

Betadine 5cc

Alkohol 70%=5cc

Chlorin 1% = 10cc

Perhidrol 3c

Albothyl 2cc 5625

ALKES Spuit 3cc 1 750

* ................... ..................... ..................... ..................... ..........................* ................... ..................... ..................... ..................... ..........................* ................... ..................... ..................... ..................... ..........................

................... ..................... ..................... ..................... ..........................Pemulangan :

................... ..................... ..................... ..................... ..........................

................... ..................... ..................... ..................... ..........................

................... ..................... ..................... ..................... ..........................

Jumlah Biaya 235,455 Kode ICD 10 Kode ICD 9 - CM K04.1

..................... * Utama ............................. * Kode INACBG"s : O33160* Penyerta ..................... ..................... *

...................... ..................... ..................... *Nama Pelaks * Komplikasi ..................... ..................... *Verifikasi : 38 ..................... ..................... *......................

Halaman 1

SMF GIGI & MULUT RSUD RAA SOEWONDO PATI 3

GANGREN PULPA, PULPITIS, CHRONIC PERIODONTITIS, PERIAPICAL ABSES Tahun 2012 5

Nama Pasien : 6 Umur : 7 Berat Badan : 8Tinggi Badan : 9Nomor Rekam Medis : 10

Diagnosis Awal :..............................11 Kode ICD 10 : 12 Rencana rawat : ..........hari 13

.....14....... .....15....... .....16....... .....17.....hari .....18....... .....19....... .....20.......

* Penyakit Utama 22


* Komplikasi 24



Tindakan : 28

Obat-obatan : 29

Nutrisi : 29

Mobilisasi : 30

Hasil (Outcome): 31


Varians : 33

Nama Perawat : 36Diagnosis Akhir 34 Jenis Tindakan 35

Nama Dokter : 37

copy of clinical pathway rajal. dr tuty

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