20090112 cmbm status lengkap obgin, rspad, jje

RSPAD GATOT SOEBROTO DITKESAD

DEPARTEMEN OBSTETRI DAN GINEKOLOGI

CATATAN MEDIK BERORIENTASI MASALAH

STATUS PASIEN OBSTETRI GINEKOLOGI

....................................................................................................... (nama pasien dan suami)

TAHUN : 2008 / 2009 / 2010 / 2011 / 2012 / 2013 / 2014 / 2015 ..................

HARAP DIBAWA SETIAP KALI PERIKSA

RAHASIA

RSPAD GATOT SOEBROTO DITKESAD Departemen Obstetri Ginekologi Jl. Abdurachman Salen no 24 Jakarta 10410

CMBM – JJE 20081225 2

DAFTAR MASALAH TETAP Nama Pasien : ........................................................ Nomor CM : ............................................

NO KLASIFIKASI MASALAH

(DIAGNOSIS KASUS) TANGGAL

MULAI TERJADI

TANGGAL MASALAH SELESAI

RINGKASAN PENATALAKSANAAN NAMA PPDS & DPJP


CMBM – JJE 20081225 3

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

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Keluhan Tambahan

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Riwayat Penyakit Sekarang

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Perangai Pasien

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Riwayat Haid

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Riwayat KB

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Riwayat Pernikahan

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CMBM – JJE 20081225 4

Riwayat Obstetri

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Riwayat Penyakit Dahulu

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Riwayat Penyakit Keluarga

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Catatan Penting Selama Asuhan Antenatal

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PEMERIKSAAN FISIK

Diperiksa oleh : ……………………………....... Tanggal :.................... Jam :.............................

Status Generalis

Keadaan Umum : ........................................... Kesadaran : .........................................................

Tinggi Badan : ..........................……cm Berat Badan : …………................................. kg

Tekanan Darah : ................................ mmHg Nadi : ......................x/menit, teratur/tidak teratur

Suhu Tubuh : .............................................oC Pernafasan : ................x/menit,teratur/tidak

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CMBM – JJE 20081225 5

Status Obstetri / Ginekologi

1. Periksa Luar :

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2. Inspekulo :

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3. Periksa Dalam :

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Pelvimetri Klinik ( khusus ibu hamil / melahirkan ): ...........................................................................................................................................................

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CMBM – JJE 20081225 6

PEMERIKSAAN PENUNJANG DIAGNOSTIK (berisi data pemeriksaan penunjang diagnostik yang sudah dimiliki pasien sebelum pemeriksaan saat ini dilakukan) ...........................................................................................................................................................

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DIAGNOSIS KERJA

IBU :

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JANIN :

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PROGNOSIS

IBU :

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JANIN :

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CMBM – JJE 20081225 7

PENATALAKSANAAN AWAL

Rencana Diagnostik :

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Rencana Terapi :

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Rencana Pendidikan :

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PPDS : ........................................................ DPJP : ................................................................

Tanda tangan : ....................................... .... Tanda tangan : ....................................................


CMBM – JJE 20081225 8

DATA PENTING LAINNYA

Nama Pasien : …………………………………. …… Nomor CM : ……………………………... TGL, JAM,

PEMERIKSA DATA PENTING LAIN YANG TERKAIT DENGAN

PENATALAKSANAAN PASIEN TANDA

TANGAN

Data yang ditulis mencakup hal penting yang dapat mempengaruhi penatalaksanaan pasien.


CMBM – JJE 20081225 9

PENATALAKSANAAN LANJUTAN ( S.O.A.P.) Nama Pasien : ........................................................ Nomor CM : ............................................ TGL, JAM,

PEMERIKSA TEMUAN KLINIS DAN PENATALAKSANAAN

(ditulis runut sesuai SOAP, dimengerti, tidak dicoret/dihapus) TANDA

TANGAN


CMBM – JJE 20081225 10




TANGAN


CMBM – JJE 20081225 11




TANGAN


CMBM – JJE 20081225 12




TANGAN


CMBM – JJE 20081225 13




TANGAN


CMBM – JJE 20081225 14




TANGAN

SOAP ini dilanjutkan pada lembar pengamatan lanjut TAMBAHAN


CMBM – JJE 20081225 15

RINGKASAN HASIL PEMERIKSAAN PENUNJANG

Nama Pasien : ................................................. ........ Nomor CM : ............................................ TGL, JAM,

PEMERIKSA HASIL PEMERIKSAAN PENUNJANG

(tulis secara ringkas hasil pemeriksaan USG, CTG, dll) TANDA

TANGAN


CMBM – JJE 20081225 16

RINGKASAN HASIL KONSULTASI ANTAR DEPARTEMEN / DIVISI Nama Pasien : ………………………………………… Nomor CM : …………………….............. TGL, JAM,

PEMERIKSA HASIL KONSULTASI

(tulis secara ringkas, dimengerti dan runut) TANDA

TANGAN


CMBM – JJE 20081225 17

RINGKASAN PERSETUJUAN TINDAK MEDIK

Nama Pasien : ……………………………………....... Nomor CM : .......................................... TGL, JAM,

PEMERIKSA PERSETUJUAN TINDAK MEDIK

(tulis secara ringkas, dimengerti, mencakup hal penting) TANDA

TANGAN


CMBM – JJE 20081225 18

SALINAN (COPY) RESEP DOKTER Nama Pasien : ……………………………………….. Nomor CM : ……………………………… TGL, JAM,

PEMERIKSA URAIAN ISI RESEP DOKTER

(mencakup nama, dosis, cara dan catatan penting obat) TANDA

TANGAN

20090112 cmbm status lengkap obgin, rspad, jje

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