LEMBAR INSUFISIENSI

NO NORM NAMA NAMA DOKTER

1 178926 SUTAMI, NY DR ARIADI, SpJP

2 550134 SULAMI, NY DR ARIADI, SpJP
3 551508 SUDARTO, TN DR ARIADI, SpJP
4 512151 IRFANDI , TN DR ARIADI, SpJP
5 551877 PAIDI, TN DR ARIADI, SpJP
6 506999 SULASIYAH, NY DR ARIADI, SpJP
7 229797 RUKMINAH, NY DR BUDI, SpJP
8 549467 NURAINI, NY DR BUDI, SpJP
9 551369 SUPINAH, NY DR BUDI, SpJP
10 054907 ASIYAH, NY DR BUDI, SpJP
11 537009 MUJIATI, NY DR BUDI, SpJP
12 553364 HARTONO, TN DR BUDI, SpJP
13 551277 MU`AROFAH, NY DR FAHMI, SpB
14 551325 FATKHIYAH NILAM AURANI, AN DR FAHMI, SpB
15 553308 KHOLIL, TN DR FAHMI, SpB
16 553327 BENI SISWANTO, TN DR FAHMI, SpB
17 543695 ABDUL RUHIN H., TN DR FAHMI, SpB
18 553267 SOFYAN HAKIM, SDR DR FAHMI, SpB
19 521849 ESTER PURNAMASARI, NY DR IWAN, SpB
20 547530 SOLIKAH, NY DR IWAN, SpB
21 214921 FAUJAN SODIG, TN DR IWAN, SpB
22 529570 MUHAMMAD AGIL SANTOSO, TN DR IWAN, SpB
23 506444 ULFAWIYAH, NY DR IWAN, SpB
24 530404 DEWI MARLINA, NY DR IWAN, SpB
25 549637 ACHMAD HADI SHOLIHIN, TN DR INDRA, SpB
26 548965 AGUS SETYO BUDI, TN DR INDRA, SpB
27 187117 MUSRIPAH, NY DR INDRA, SpB
28 551814 ALI FATKUR, SDR DR INDRA, SpB
29 550496 EDY PURNOMO, TN DR INDRA, SpB
30 121613 SUGIONO,TN DR INDRA, SpB
31 545996 SUTONO ADI SURYANTO, TN DR HADIQ, SpD
32 549622 YUNI ASTUTIK, NY DR HADIQ, SpD
33 034760 KASMAN, TN DR HADIQ, SpD
34 549018 AKBAR PERMANA DIMAS PUTRA, SDR DR HADIQ, SpD
35 551346 KASTO, TN DR HADIQ, SpD
36 539132 UNIK SULISTIYANINGSIH, NY DR HADIQ, SpD
37 549588 PUTRI AYU PATRESIA, NN DR IWAN, SpD
38 162332 NUR HADI, TN DR IWAN, SpD
39 508733 SUBUR, TN DR IWAN, SpD
40 551932 ROTAH, NY DR IWAN, SpD
41 551606 SABAR, TN DR IWAN, SpD
42 553290 MUNIB, TN DR IWAN, SpD
43 213143 RIKA SUGIANTI, NY DR WISNU, SpOG
44 527412 NUR SULISTYOWATI, NY DR WISNU, SpOG
45 551599 EVI WIJAYANTI, NY DR WISNU, SpOG
46 551598 IDA YANTI, NY DR WISNU, SpOG
47 538322 DWI RAHAYU ,NY DR WISNU, SpOG
48 188000 WIWIN SUSANTI, NY DR WISNU, SpOG
49 550095 DITA ALAM SAFITRI, NY DR LINDA, SpOG
50 550097 DIANA, NY DR LINDA, SpOG
51 551519 ERWIN WAHYUNI, NY DR LINDA, SpOG
52 171042 DWI ARIES TIYANINGSIH, NY DR LINDA, SpOG
53 551550 IIS SUHARTININGSIH, NY DR LINDA, SpOG
54 182510 DWI YULIARISTIANA,NN DR LINDA, SpOG
55 190668 MUHAMMAD AL KAUTSAR PUTRA.P, AN DR BAGUS, SpA
56 532736 TRI RAHMAWATI, AN DR BAGUS, SpA
57 553310 DESTIAN ARDIANSYAH,AN DR BAGUS, SpA
58 553387 MIFTA FEBIANA, BY NY DR BAGUS, SpA
59 553398 IIS ARISKA, BY NY DR BAGUS, SpA
60 553399 HENI KURNIAWATI, BY NY DR BAGUS, SpA
61 536907 CLARESTIA CANDRAWATI K, AN DR WORO, SpA
62 550391 MOCH HAFIZH IKBAARRUDDIN, AN DR WORO, SpA
63 552532 HARIS DEVANKA PRADANA, AN DR WORO, SpA
64 552737 WILMA NAZALUDIN NASWA, AN DR WORO, SpA
65 502053 KHAYLA ALMIRA MARITZA, AN DR WORO, SpA
66 516387 TASMIRA MAUHIBATI RAMADHANI, AN DR WORO, SpA
67 539166 CITRA CLARITA ROHMADINA, AN DR MAHFUR, SpA
68 549800 SUCI CHOIRUNNIKMAH, BY NY DR MAHFUR, SpA
69 536884 JIHAN ZAHIRRA, AN DR MAHFUR, SpA
70 547369 ALFIYATUL HANIAH, AN DR MAHFUR, SpA
71 529919 RAISYA KAYLA APRILIANA Z, AN DR MAHFUR, SpA
72 529001 HANNA QONITA ABDILLAH, AN DR MAHFUR, SpA
73 548466 MOCH SOLEH, TN DR MAKIN, SpS
74 046091 MUHAMMAD SYAFII, TN DR MAKIN, SpS
75 551097 NUR FARIDAH, NY DR MAKIN, SpS
76 551278 JUNI, NY DR MAKIN, SpS
77 047536 SAMIATI, NY DR MAKIN, SpS
78 553413 SITI JENAB, NY DR MAKIN, SpS
79 553513 TRIASIH, NY DR ISTI SpS
80 510899 TAKIM, TN DR ISTI SpS
81 551268 RIJAN, TN DR ISTI SpS
82 551080 SUMINAH, NY DR ISTI SpS
83 231689 MOCHTAR, TN H DR ISTI SpS
84 549332 TEMU HAJAH, NY DR ISTI SpS
 85 549651 ROBIYANSYAH, SDR DR GUNAWAN, SpORT
86 549706 MOH MIFTAH, TN DR GUNAWAN, SpORT
87 552800 ALI SOFI, TN DR GUNAWAN, SpORT
88 544224 ZAENUDIN , TN DR GUNAWAN, SpORT
89 552581 SAPTAJI, TN DR GUNAWAN, SpORT
90 554472 SITI MAUH DU`AH, NY DR GUNAWAN, SpORT
91 549838 FARIZ JOAN SYAHPUTRA, SDR DR JUDY PERMANA, SpORT
92 549886 ALFIAN SETYO BUDHI, SDR DR JUDY PERMANA, SpORT
93 551800 LINDA ALKOMA, AN DR JUDY PERMANA, SpORT
94 551941 DWI PUTRA SYAHRUL RAMADHAN, AN DR JUDY PERMANA, SpORT
95 551828 DULAZIZ, TN DR JUDY PERMANA, SpORT
96 553752 RIFKY MAULANA, SDR DR JUDY PERMANA, SpORT
97 549431 UMMU FAROHAH, NN DR WIMBA, SpBS
98 549642 MARI SUDARJANTININGSIH, NY DR WIMBA, SpBS
99 552330 TIANAH, NY HJ DR WIMBA, SpBS
100 552287 THORIQUL FAHRI, SDR DR WIMBA, SpBS
101 552212 JONO, TN DR WIMBA, SpBS
102 553617 MOCH RIDWAN YASIN, SDR DR WIMBA, SpBS
103 504362 IMAM SUYATNO, TN DR DAVID, SpBS
104 542977 ANANG ARIF WIBOWO, SDR DR DAVID, SpBS
105 553547 MARIYO, TN DR DAVID, SpBS
106 553616 ALI MASHUDI, TN DR DAVID, SpBS
107 553795 SITI KHOIRIYAH,NY DR DAVID, SpBS
108 553956 SUYATIM, TN DR DAVID, SpBS
109 542756 SUMARJI , TN DR CANDRA, SpU
110 545760 KUSNUL ROFIK, TN DR CANDRA, SpU
111 551482 SITI MARIYAM, NY DR CANDRA, SpU
112 133555 JASMAN, TN DR CANDRA, SpU
113 505262 ACHMAD CHAMIM, TN DR CANDRA, SpU
114 552045 TOTOK ARIFFIANTO, TN DR CANDRA, SpU
115 058969 DRAI ,TN DR CANDRA, SpU
116 550078 IRMA MELINDA, AN DR NENDYO, SpTHT
117 549109 ISNAWATI, NY DR NENDYO, SpTHT
118 550676 JONARDO ADI CANDRA, SDR DR NENDYO, SpTHT
119 153926 MAYSADIYAH, NY DR NENDYO, SpTHT
120 553216 SARIYAH, NY DR NENDYO, SpTHT
121 554050 MOHAMMAD TAUFIK EFENDI, TN DR NENDYO, SpTHT
122 230823 SUMIRAH, NY DR NENDYO, SpTHT
123 550005 SITI CHOLIFAH, NY DR EKACANDRA, SpKK
124 222241 FAHRA RAHMADHANI, AN DR EKACANDRA, SpKK
125 550593 SULTON, TN DR EKACANDRA, SpKK
126 552198 SITI NURUL AINI, NY DR EKACANDRA, SpKK
127 544428 MURTIDJAH, NY DR EKACANDRA, SpKK
128 554240 ANI MURWATI, NY DR EKACANDRA, SpKK
EMBAR INSUFISIENSI

KODE ICD SESUAI

ASKEP CATATAN
TANDA INFORMED KONSISTE
DIAGNOSA
TANGAN CONSENT TERBACA
N
YA TIDAK DOKTER
DC √ √ √ √ -
DC √ √ √ √ -
HHD √ √ √ √ √
RHD √ √ √ √ √
DC √ √ √ √ √
AF √ √ √ √ √
HHD √ √ √ √ √
DC √ √ √ √ -
DC √ √ √ √ √
PJK √ √ √ √ -
HHF √ √ √ √ √
PJK √ √ √ √ -
HIL √ √ √ √ √
VULNUS LACERASI √ √ √ √ √
DM DENGAN GANGRENE √ √ √ √ √
BURN GR 2 √ √ √ √ -
APENDIK PERFORASI √ √ √ √ √
CF MAXILA & CLAVICULA √ √ √ √ √
STRUMA NODULAR √ √ √ √ √
TUMOR COLON √ √ √ √ √
HERNIA UMBILICAL √ √ √ √ √
POST ORIF MAXILA √ √ √ √ √
TU DINDING ABDOMEN √ √ √ √ √
ABSES LABIA MAYOR √ √ √ √ √
IELUS PARALITIK √ √ √ √ √
SOFT TISUE TUMOR √ √ √ √ √
HEMOROID INTERNA √ √ √ √ -
CRUSHING INJURY √ √ √ √ √
ABSES SUBMANDIBUL √ √ √ √ √
ULCUS SELULITIS PEDIS √ √ √ √ √
CYSTITIS √ √ √ - √
GASTRITIS AKUT √ √ √ √ √
TU PARU METASTASE √ √ √ √ -
DSS √ √ √ √ √
CKD + ANEMIA √ √ √ √ -
CA MAMAE + ASCITES √ √ √ √ -
DHF √ √ √ √ √
GASTRITIS AKUT √ √ √ - -
DM + ULCUS PEDIS √ √ √ √ √
CKD √ √ √ - -
DMND + SEPSIS √ √ √ √ √
DMND + SEPSIS √ √ √ √ √
HG √ √ √ √ √
POST SC + KPD √ √ √ √ √
POST SC + KPD √ √ √ √ √
POST SC √ √ √ √ √
POST SC + POST DATE √ √ √ √ √
CYSTA OVARI √ √ √ √ √
POST SC + KPD √ √ √ √ √
POST SC + KPD √ √ √ √ √
POST SC + PER √ √ √ √ -
AB IMINEN √ √ √ √ √
POST SC √ √ √ √ √
HG √ √ √ √ √
DF √ √ √ √ √
DF √ √ √ √ √
BRONKITIS √ √ √ √ √
SEPSIS + NA √ √ √ √ √
NA + SIB √ √ √ √ √
ASFIKSIA + NA √ √ √ √ √
DF √ √ √ √ √
DF √ √ √ √ √
TF √ √ √ √ √
TF √ √ √ √ √
FEVER √ √ √ √ -
LEUKOSITOSIS √ √ √ √ √
DF + BRONKITIS √ √ √ √ √
SEPSIS + BBLR √ √ √ √ √
FARINGITIS + BRONKITIS √ √ √ √ √
GEA √ √ √ √ √
GEA + BRONKITIS √ √ √ √ √
VOMIT + DEHIDRASI √ √ √ √ √
CVA INFARK + SEPSIS √ √ √ √ -
CVA INFARK √ √ √ √ √
CVA EMBOLI √ √ √ √ √
TTH √ √ √ √ √
VERTIGO √ √ √ √ √
CVA INFARK √ √ √ √ √
CVA INFARK + DM √ √ √ √ √
LBP √ √ √ √ √
LBP √ √ √ √ √
STROKE STROMBOTIK √ √ √ √ √
CVA INFARK TROMBOTIK √ √ √ √ -
CVA INFARK √ √ √ √ √
VA MANUS √ √ √ √ √
CF ULNA √ √ √ √ √
OFR DIG IV PEDIS √ √ √ √ -
OF DIF 2 MANUS √ √ √ √ √
CF VERTEBRA LUMBAL √ √ √ √ √
OF DIG 2,3,4 √ √ √ √ √
CF DIG 4 MANUS √ √ √ √ √
CF METATARSAL √ √ √ √ -
CF FEMUR √ √ √ √ √
CF TIBIA √ √ √ √ √
CRUSH INJURY MANUS √ √ √ √ √
CF ANTEBRACHI √ √ √ √ √
FR MANDIBULAR √ √ √ √ √
COB + EDH √ √ √ √ -
COR √ √ √ √ √
CF ANTEBRACHI √ √ √ √ √
COR + EDH √ √ √ √ √
COS + FR MANDIBULAR √ √ √ - -
COR + SCALP HEMATOM √ √ √ √ √
COB √ - √ - -
COR + TRAUMA OPTIK √ √ √ √ √
COR + CF CALVICULA √ √ √ √ √
COR + SCALP HEMATOM √ √ √ √ √
COR √ √ √ √ √
CA PROSTAT √ √ √ √ √
BATU URETER + HN √ √ √ √ -
HN + AKI √ √ √ √ √
BBB + BPH √ √ √ √ √
COLIK RENAL √ √ √ √ √
ISK √ √ √ √ √
BPH + ISK √ √ √ √ √
TONSILITIS √ √ - √ -
SINUSITIS √ √ √ √ √
TONSILITIS √ √ √ √ √
SINUSITIS √ √ √ √ √
PERITONSIL INFILTRAT √ √ √ √ √
SINUSITIS √ √ √ √ √
POLIP NASAL + SINUSITIS √ √ √ √ √
HERPES ZOOSTER √ √ √ √ √
MOLLUSCOM CONTAGIOSU √ √ √ √ √
DRUG ERUPTION √ √ √ √ √
ERYTRODERMA √ √ √ √ √
STEVEN JHONSON SYNDRO √ √ √ √ √
ERUPSI OBAT √ √ √ √ √
NB: Berikan tanda (√) untuk kategori LENGKAP
Berikan tanda (-) untuk kategori TIDAK LENGKAP
 LEMBAR INSUFISIENSI

NO NORM NAMA NAMA DOKTER

1 178926 SUTAMI, NY DR ARIADI, SpJP

2 550134 SULAMI, NY DR ARIADI, SpJP
3 551508 SUDARTO, TN DR ARIADI, SpJP
4 512151 IRFANDI , TN DR ARIADI, SpJP
5 551877 PAIDI, TN DR ARIADI, SpJP
6 506999 SULASIYAH, NY DR ARIADI, SpJP
7 229797 RUKMINAH, NY DR BUDI, SpJP
8 549467 NURAINI, NY DR BUDI, SpJP
9 551369 SUPINAH, NY DR BUDI, SpJP
10 054907 ASIYAH, NY DR BUDI, SpJP
11 537009 MUJIATI, NY DR BUDI, SpJP
12 553364 HARTONO, TN DR BUDI, SpJP
13 551277 MU`AROFAH, NY DR FAHMI, SpB
14 551325 FATKHIYAH NILAM AURANI, AN DR FAHMI, SpB
15 553308 KHOLIL, TN DR FAHMI, SpB
16 553327 BENI SISWANTO, TN DR FAHMI, SpB
17 543695 ABDUL RUHIN H., TN DR FAHMI, SpB
18 553267 SOFYAN HAKIM, SDR DR FAHMI, SpB
19 521849 ESTER PURNAMASARI, NY DR IWAN, SpB
20 547530 SOLIKAH, NY DR IWAN, SpB
21 214921 FAUJAN SODIG, TN DR IWAN, SpB
22 529570 MUHAMMAD AGIL SANTOSO, TN DR IWAN, SpB
23 506444 ULFAWIYAH, NY DR IWAN, SpB
24 530404 DEWI MARLINA, NY DR IWAN, SpB
25 549637 ACHMAD HADI SHOLIHIN, TN DR INDRA, SpB
26 548965 AGUS SETYO BUDI, TN DR INDRA, SpB
27 187117 MUSRIPAH, NY DR INDRA, SpB
28 551814 ALI FATKUR, SDR DR INDRA, SpB
29 550496 EDY PURNOMO, TN DR INDRA, SpB
30 121613 SUGIONO,TN DR INDRA, SpB
31 545996 SUTONO ADI SURYANTO, TN DR HADIQ, SpD
32 549622 YUNI ASTUTIK, NY DR HADIQ, SpD
33 034760 KASMAN, TN DR HADIQ, SpD
34 549018 AKBAR PERMANA DIMAS PUTRA, SDR DR HADIQ, SpD
35 551346 KASTO, TN DR HADIQ, SpD
36 539132 UNIK SULISTIYANINGSIH, NY DR HADIQ, SpD
37 549588 PUTRI AYU PATRESIA, NN DR IWAN, SpD
38 162332 NUR HADI, TN DR IWAN, SpD
39 508733 SUBUR, TN DR IWAN, SpD
40 551932 ROTAH, NY DR IWAN, SpD
41 551606 SABAR, TN DR IWAN, SpD
42 553290 MUNIB, TN DR IWAN, SpD
43 213143 RIKA SUGIANTI, NY DR WISNU, SpOG
44 527412 NUR SULISTYOWATI, NY DR WISNU, SpOG
45 551599 EVI WIJAYANTI, NY DR WISNU, SpOG
46 551598 IDA YANTI, NY DR WISNU, SpOG
47 538322 DWI RAHAYU ,NY DR WISNU, SpOG
48 188000 WIWIN SUSANTI, NY DR WISNU, SpOG
49 550095 DITA ALAM SAFITRI, NY DR LINDA, SpOG
50 550097 DIANA, NY DR LINDA, SpOG
51 551519 ERWIN WAHYUNI, NY DR LINDA, SpOG
52 171042 DWI ARIES TIYANINGSIH, NY DR LINDA, SpOG
53 551550 IIS SUHARTININGSIH, NY DR LINDA, SpOG
54 182510 DWI YULIARISTIANA,NN DR LINDA, SpOG
55 190668 MUHAMMAD AL KAUTSAR PUTRA.P, AN DR BAGUS, SpA
56 532736 TRI RAHMAWATI, AN DR BAGUS, SpA
57 553310 DESTIAN ARDIANSYAH,AN DR BAGUS, SpA
58 553387 MIFTA FEBIANA, BY NY DR BAGUS, SpA
59 553398 IIS ARISKA, BY NY DR BAGUS, SpA
60 553399 HENI KURNIAWATI, BY NY DR BAGUS, SpA
61 536907 CLARESTIA CANDRAWATI K, AN DR WORO, SpA
62 550391 MOCH HAFIZH IKBAARRUDDIN, AN DR WORO, SpA
63 552532 HARIS DEVANKA PRADANA, AN DR WORO, SpA
64 552737 WILMA NAZALUDIN NASWA, AN DR WORO, SpA
65 502053 KHAYLA ALMIRA MARITZA, AN DR WORO, SpA
66 516387 TASMIRA MAUHIBATI RAMADHANI, AN DR WORO, SpA
67 539166 CITRA CLARITA ROHMADINA, AN DR MAHFUR, SpA
68 549800 SUCI CHOIRUNNIKMAH, BY NY DR MAHFUR, SpA
69 536884 JIHAN ZAHIRRA, AN DR MAHFUR, SpA
70 547369 ALFIYATUL HANIAH, AN DR MAHFUR, SpA
71 529919 RAISYA KAYLA APRILIANA Z, AN DR MAHFUR, SpA
72 529001 HANNA QONITA ABDILLAH, AN DR MAHFUR, SpA
73 548466 MOCH SOLEH, TN DR MAKIN, SpS
74 046091 MUHAMMAD SYAFII, TN DR MAKIN, SpS
75 551097 NUR FARIDAH, NY DR MAKIN, SpS
76 551278 JUNI, NY DR MAKIN, SpS
77 047536 SAMIATI, NY DR MAKIN, SpS
78 553413 SITI JENAB, NY DR MAKIN, SpS
79 553513 TRIASIH, NY DR ISTI SpS
80 510899 TAKIM, TN DR ISTI SpS
81 551268 RIJAN, TN DR ISTI SpS
82 551080 SUMINAH, NY DR ISTI SpS
83 231689 MOCHTAR, TN H DR ISTI SpS
84 549332 TEMU HAJAH, NY DR ISTI SpS
85 549651 ROBIYANSYAH, SDR DR GUNAWAN, SpORT
 86 549706 MOH MIFTAH, TN DR GUNAWAN, SpORT
87 552800 ALI SOFI, TN DR GUNAWAN, SpORT
88 544224 ZAENUDIN , TN DR GUNAWAN, SpORT
89 552581 SAPTAJI, TN DR GUNAWAN, SpORT
90 554472 SITI MAUH DU`AH, NY DR GUNAWAN, SpORT
91 549838 FARIZ JOAN SYAHPUTRA, SDR DR JUDY PERMANA, SpORT
92 549886 ALFIAN SETYO BUDHI, SDR DR JUDY PERMANA, SpORT
93 551800 LINDA ALKOMA, AN DR JUDY PERMANA, SpORT
94 551941 DWI PUTRA SYAHRUL RAMADHAN, AN DR JUDY PERMANA, SpORT
95 551828 DULAZIZ, TN DR JUDY PERMANA, SpORT
96 553752 RIFKY MAULANA, SDR DR JUDY PERMANA, SpORT
97 549431 UMMU FAROHAH, NN DR WIMBA, SpBS
98 549642 MARI SUDARJANTININGSIH, NY DR WIMBA, SpBS
99 552330 TIANAH, NY HJ DR WIMBA, SpBS
100 552287 THORIQUL FAHRI, SDR DR WIMBA, SpBS
101 552212 JONO, TN DR WIMBA, SpBS
102 553617 MOCH RIDWAN YASIN, SDR DR WIMBA, SpBS
103 504362 IMAM SUYATNO, TN DR DAVID, SpBS
104 542977 ANANG ARIF WIBOWO, SDR DR DAVID, SpBS
105 553547 MARIYO, TN DR DAVID, SpBS
106 553616 ALI MASHUDI, TN DR DAVID, SpBS
107 553795 SITI KHOIRIYAH,NY DR DAVID, SpBS
108 553956 SUYATIM, TN DR DAVID, SpBS
109 542756 SUMARJI , TN DR CANDRA, SpU
110 545760 KUSNUL ROFIK, TN DR CANDRA, SpU
111 551482 SITI MARIYAM, NY DR CANDRA, SpU
112 133555 JASMAN, TN DR CANDRA, SpU
113 505262 ACHMAD CHAMIM, TN DR CANDRA, SpU
114 552045 TOTOK ARIFFIANTO, TN DR CANDRA, SpU
115 058969 DRAI ,TN DR CANDRA, SpU
116 550078 IRMA MELINDA, AN DR NENDYO, SpTHT
117 549109 ISNAWATI, NY DR NENDYO, SpTHT
118 550676 JONARDO ADI CANDRA, SDR DR NENDYO, SpTHT
119 153926 MAYSADIYAH, NY DR NENDYO, SpTHT
120 553216 SARIYAH, NY DR NENDYO, SpTHT
121 554050 MOHAMMAD TAUFIK EFENDI, TN DR NENDYO, SpTHT
122 230823 SUMIRAH, NY DR NENDYO, SpTHT
123 550005 SITI CHOLIFAH, NY DR EKACANDRA, SpKK
124 222241 FAHRA RAHMADHANI, AN DR EKACANDRA, SpKK
125 550593 SULTON, TN DR EKACANDRA, SpKK
126 552198 SITI NURUL AINI, NY DR EKACANDRA, SpKK
127 544428 MURTIDJAH, NY DR EKACANDRA, SpKK
128 554240 ANI MURWATI, NY DR EKACANDRA, SpKK
NB: Berikan tanda (√) untuk kategori LENGKAP
Berikan tanda (-) untuk kategori TIDAK LENGKAP
MBAR INSUFISIENSI

KODE ICD SESUAI TANDA INFORME ASKEP CATATAN SIMBOL

&
DIAGNOSA TANGAN D KONSIST TERBAC
SINGKAT
YA TIDAK DOKTER CONSENT EN A
AN
DC √ √ √ √ - -
DC √ √ √ √ - √
HHD √ √ √ √ √ √
RHD √ √ √ √ √ √
DC √ √ √ √ √ √
AF √ √ √ √ √ √
HHD √ √ √ √ √ √
DC √ √ √ √ - √
DC √ √ √ √ √ √
PJK √ √ √ √ - -
HHF √ √ √ √ √ √
PJK √ √ √ √ - √
HIL √ √ √ √ √ √
VULNUS LACERASI √ √ √ √ √ √
DM DENGAN GANGRENE √ √ √ √ √ √
BURN GR 2 √ √ √ √ - √
APENDIK PERFORASI √ √ √ √ √ √
CF MAXILA & CLAVICUL √ √ √ √ √ √
STRUMA NODULAR √ √ √ √ √ √
TUMOR COLON √ √ √ √ √ √
HERNIA UMBILICAL √ √ √ √ √ √
POST ORIF MAXILA √ √ √ √ √ √
TU DINDING ABDOMEN √ √ √ √ √ √
ABSES LABIA MAYOR √ √ √ √ √ √
IELUS PARALITIK √ √ √ √ √ √
SOFT TISUE TUMOR √ √ √ √ √ √
HEMOROID INTERNA √ √ √ √ - -
CRUSHING INJURY √ √ √ √ √ √
ABSES SUBMANDIBUL √ √ √ √ √ √
ULCUS SELULITIS PEDIS √ √ √ √ √ √
CYSTITIS √ √ √ - √ √
GASTRITIS AKUT √ √ √ √ √ √
TU PARU METASTASE √ √ √ √ - √
DSS √ √ √ √ √ √
CKD + ANEMIA √ √ √ √ - √
CA MAMAE + ASCITES √ √ √ √ - -
DHF √ √ √ √ √ √
GASTRITIS AKUT √ √ √ - - -
DM + ULCUS PEDIS √ √ √ √ √ √
CKD √ √ √ - - √
DMND + SEPSIS √ √ √ √ √ √
DMND + SEPSIS √ √ √ √ √ √
HG √ √ √ √ √ √
POST SC + KPD √ √ √ √ √ √
POST SC + KPD √ √ √ √ √ √
POST SC √ √ √ √ √ √
POST SC + POST DATE √ √ √ √ √ √
CYSTA OVARI √ √ √ √ √ √
POST SC + KPD √ √ √ √ √ √
POST SC + KPD √ √ √ √ √ √
POST SC + PER √ √ √ √ - -
AB IMINEN √ √ √ √ √ √
POST SC √ √ √ √ √ √
HG √ √ √ √ √ √
DF √ √ √ √ √ √
DF √ √ √ √ √ √
BRONKITIS √ √ √ √ √ √
SEPSIS + NA √ √ √ √ √ √
NA + SIB √ √ √ √ √ √
ASFIKSIA + NA √ √ √ √ √ √
DF √ √ √ √ √ √
DF √ √ √ √ √ √
TF √ √ √ √ √ √
TF √ √ √ √ √ √
FEVER √ √ √ √ - -
LEUKOSITOSIS √ √ √ √ √ √
DF + BRONKITIS √ √ √ √ √ √
SEPSIS + BBLR √ √ √ √ √ √
FARINGITIS + BRONKITI √ √ √ √ √ √
GEA √ √ √ √ √ √
GEA + BRONKITIS √ √ √ √ √ √
VOMIT + DEHIDRASI √ √ √ √ √ √
CVA INFARK + SEPSIS √ √ √ √ - √
CVA INFARK √ √ √ √ √ √
CVA EMBOLI √ √ √ √ √ √
TTH √ √ √ √ √ √
VERTIGO √ √ √ √ √ √
CVA INFARK √ √ √ √ √ √
CVA INFARK + DM √ √ √ √ √ √
LBP √ √ √ √ √ √
LBP √ √ √ √ √ √
STROKE STROMBOTIK √ √ √ √ √ √
CVA INFARK TROMBOTI √ √ √ √ - √
CVA INFARK √ √ √ √ √ √
VA MANUS √ √ √ √ √ √
CF ULNA √ √ √ √ √ √
OFR DIG IV PEDIS √ √ √ √ - -
OF DIF 2 MANUS √ √ √ √ √ √
CF VERTEBRA LUMBAL √ √ √ √ √ √
OF DIG 2,3,4 √ √ √ √ √ √
CF DIG 4 MANUS √ √ √ √ √ √
CF METATARSAL √ √ √ √ - √
CF FEMUR √ √ √ √ √ √
CF TIBIA √ √ √ √ √ √
CRUSH INJURY MANUS √ √ √ √ √ √
CF ANTEBRACHI √ √ √ √ √ √
FR MANDIBULAR √ √ √ √ √ √
COB + EDH √ √ √ √ - √
COR √ √ √ √ √ √
CF ANTEBRACHI √ √ √ √ √ √
COR + EDH √ √ √ √ √ √
COS + FR MANDIBULAR √ √ √ - - -
COR + SCALP HEMATOM √ √ √ √ √ √
COB √ - √ - - -
COR + TRAUMA OPTIK √ √ √ √ √ √
COR + CF CALVICULA √ √ √ √ √ √
COR + SCALP HEMATOM √ √ √ √ √ √
COR √ √ √ √ √ √
CA PROSTAT √ √ √ √ √ √
BATU URETER + HN √ √ √ √ - √
HN + AKI √ √ √ √ √ √
BBB + BPH √ √ √ √ √ √
COLIK RENAL √ √ √ √ √ √
ISK √ √ √ √ √ √
BPH + ISK √ √ √ √ √ √
TONSILITIS √ √ - √ - √
SINUSITIS √ √ √ √ √ √
TONSILITIS √ √ √ √ √ √
SINUSITIS √ √ √ √ √ √
PERITONSIL INFILTRAT √ √ √ √ √ √
SINUSITIS √ √ √ √ √ √
POLIP NASAL + SINUSITI √ √ √ √ √ √
HERPES ZOOSTER √ √ √ √ √ √
MOLLUSCOM CONTAGI √ √ √ √ √ √
DRUG ERUPTION √ √ √ √ √ √
ERYTRODERMA √ √ √ √ √ √
STEVEN JHONSON SYN √ √ √ √ √ √
ERUPSI OBAT √ √ √ √ √ √
 LEMBAR INSUFISIENSI

NO NORM NAMA NAMA DOKTER

1 522288 ISWANTO, TN DR ARIADI, SpJP

2 554799 SONY, NY DR ARIADI, SpJP
3 557136 SUYATIN, NY DR ARIADI, SpJP
4 500601 SUYITNO UTOMO, TN DR ARIADI, SpJP
5 134099 MUJIB, TN DR ARIADI, SpJP
6 546507 KARNAWI, TN DR ARIADI, SpJP
7 554739 SITI CHOTIDJAH, NY DR BUDI, SpJP
8 143674 PONIMAN, TN DR BUDI, SpJP
9 555913 SUPENI, NY DR BUDI, SpJP
10 522166 RIANI, NY DR BUDI, SpJP
11 558898 ANIK WINARSIH, NY DR BUDI, SpJP
12 011406 ASMIAN.TN DR BUDI, SpJP
13 554829 M IKWAN, TN DR FAHMI, SpB
14 514151 SUHERMANTO, TN DR FAHMI, SpB
15 557147 MOHAMAD SOFYAN, TN DR FAHMI, SpB
16 557301 GIYANTO,TN DR FAHMI, SpB
17 559693 DAFID FANDIKA, SDR DR FAHMI, SpB
18 559870 HANDOYO, TN DR FAHMI, SpB
19 554938 JOKO PUJI SUSIANTO , TN DR IWAN, SpB
20 555033 SAIPARTO, TN DR IWAN, SpB
21 557375 NOVIA LAURITA, NN DR IWAN, SpB
22 028536 NUR CHALIM, TN DR IWAN, SpB
23 560379 DIDIK SANTOSO, TN DR IWAN, SpB
24 527876 JONI, TN DR IWAN, SpB
25 554336 SUGENG HARIADI, TN DR INDRA, SpB
26 555031 NGATEMI, NY DR INDRA, SpB
27 556900 ARIS FIANTO, TN DR INDRA, SpB
28 556960 AHMAD FAHRI KHUSNI, AN DR INDRA, SpB
29 559762 SITI ROFIAH, NY DR INDRA, SpB
30 558713 DWI KHOIRUN NISAK, NY DR INDRA, SpB
31 554878 MUJI SANTOSO, TN DR HADIQ, SpD
32 554892 NURUL HIDAYATI, NY DR HADIQ, SpD
33 556811 SANAH, NY DR HADIQ, SpD
34 556712 MISTI, NY DR HADIQ, SpD
35 194061 NILAM INDAH YULIANI, NY DR HADIQ, SpD
36 560115 ABDUL QOLIQ, TN DR HADIQ, SpD
37 554745 SUPINI, NY DR IWAN, SpD
38 554879ALEKSANDRIA VICTOR PRADANA, SDR DR IWAN, SpD
39 557049 KEMINING, NY DR IWAN, SpD
40 523925 RIYAN ZAAHID SAPUTRA, SDR DR IWAN, SpD
41 560329 DWI AMINUDIN , SDR DR IWAN, SpD
42 558859 INES DHEN FITRIA, NY DR IWAN, SpD
43 543361 DITA PUTRI NOVIANI, NY DR WISNU, SpOG
44 555035 ANIS LIAWATI, NY DR WISNU, SpOG
45 556901 DISTRIANI, NY DR WISNU, SpOG
46 556989 PUJIATI, NY DR WISNU, SpOG
47 549297 ANDI EKA JUMIARTY, NY DR WISNU, SpOG
48 513354 NOOR AFNI EKAWATI, NY DR WISNU, SpOG
49 554929 ZULIATIN, NY DR LINDA, SpOG
50 542278 DIAN FITRIAFIANI AGUSTIN, NY DR LINDA, SpOG
51 557452 ERMA SETYOWATI, NY DR LINDA, SpOG
52 557344 ELGA YANU ARISTI, NY DR LINDA, SpOG
53 557449 IRMA SETIANI, NY DR LINDA, SpOG
54 560690 FERRY ANDRIANI, NY DR LINDA, SpOG
55 554773 ANA DEWI ARISTA, BY NY DR BAGUS, SpA
56 554847 ADITYA NAUFAL ABIYU, AN DR BAGUS, SpA
57 556745
WINARSIH EKA SETYANINGTYAS, BY NY DR BAGUS, SpA
58 556830 ELVIA ANGGRAINI, AN DR BAGUS, SpA
59 540413 VIARA NAWANG ASIH SURYANI, AN DR BAGUS, SpA
60 560201 KHOIRANI KHUMAYROH, BY NY DR BAGUS, SpA
61 556043MUHAMMAD ELMAN THOLIBIN, AN DR WORO, SpA
62 523517 AHMAD FATHIR ARZIKI, AN DR WORO, SpA
63 558183 AISYAH NABILA PUTRI F, AN DR WORO, SpA
64 558621 ARJUNA DANA,AN DR WORO, SpA
65 560520KHODIJAH SAYYIDATUL UMMAH, AN DR WORO, SpA
66 560619 LEVIANO DWI FERNANDO, AN DR WORO, SpA
67 555829
ARJUNA ARSYAD RAMADHANSYAH, AN DR MAHFUR, SpA
68 213753 NAYAKA ARYODIANTO, AN DR MAHFUR, SpA
69 545188
ARDHINA DWI NUR ROSTIANINGSIH, AN DR MAHFUR, SpA
70 556366 ACHMAD SAYBAN AL GHOZALI, AN DR MAHFUR, SpA
71 189157 FINA SAHILA RAHMAH, AN DR MAHFUR, SpA
72 543705 RANIA APTA YUDIANTO, AN DR MAHFUR, SpA
73 554766 SUMARSIH, NY DR MAKIN, SpS
74 554792 KUSIATIN, NY DR MAKIN, SpS
75 520494 GINI, NY DR MAKIN, SpS
76 123277 GINAH, NY DR MAKIN, SpS
77 558575 RUMIATI, NY DR MAKIN, SpS
78 549264 SUTRISNI, NY DR MAKIN, SpS
79 555415 VENDA BERIA SARI, AN DR ISTI SpS
80 547864 ABDULLOH SATAR, TN DR ISTI SpS
81 556932 PUJIARTO, TN DR ISTI SpS
82 502101 SAMIATI, NY DR ISTI SpS
83 558858 MARINA, NY DR ISTI SpS
84 534208 SAMAH, NY DR ISTI SpS
85 507487 DEWI SAWIJI, NY DR GUNAWAN, SpORT
 86 509168 M DWI CANDRA, AN DR GUNAWAN, SpORT
87 099071 SUTRISNO, TN DR GUNAWAN, SpORT
88 557793 MISROAH, NY DR GUNAWAN, SpORT
89 558765 AGIS BIL QITSI, AN DR GUNAWAN, SpORT
90 530970 MUKLIS WIBOWO, TN DR GUNAWAN, SpORT
91 554882 ITA ISTIANA, NY DR JUDY PERMANA, SpORT
92 054629 SARMAD, TN DR JUDY PERMANA, SpORT
93 557227 JOKO KASIONO, TN DR JUDY PERMANA, SpORT
94 509378 INDAH TRI NUR AINI, NY DR JUDY PERMANA, SpORT
95 559029 DAIMAN, TN DR JUDY PERMANA, SpORT
96 558891 PRASETYA WIDODO RAFAEL, TN DR JUDY PERMANA, SpORT
97 556550 IRWAN ARDIAN, SDR DR WIMBA, SpBS
98 556516 WAHYU ADHI KRINAWA, SDR DR WIMBA, SpBS
99 548743 HERU NGATIONO, TN DR WIMBA, SpBS
100 556039 SUHARTINI, NY DR WIMBA, SpBS
101 555971 MUH ILHAM ZAIN, AN DR WIMBA, SpBS
102 555968 NGAINAN, TN DR WIMBA, SpBS
103 555360 ALMA ARIF ARRAHMAN, SDR DR DAVID, SpBS
104 555188 SULISTYOWATI , NY DR DAVID, SpBS
105 556803 HAFIZA SYANI MAULIDIYA, AN DR DAVID, SpBS
106 556988 YOLANDA AYU A, NN DR DAVID, SpBS
107 560096 DA`I, TN DR DAVID, SpBS
108 560190 PUTRI LUTFIA, NN DR DAVID, SpBS
109 528910 MUBAJINAH, NY DR CANDRA, SpU
110 115223 KAMSIYAH, NY DR CANDRA, SpU
111 079410 MAT DJAI.H, TN DR CANDRA, SpU
112 224280 NUR LAILI AKROMA, NY DR CANDRA, SpU
113 557084 AJIR, TN DR CANDRA, SpU
114 549407 VICKY AHMAD MARDIANTO, SDR DR CANDRA, SpU
115 555319 HARRIS BOY NOVELLINDO, SDR DR NENDYO, SpTHT
116 555244 ACHMAD SYAFIQ, AN DR NENDYO, SpTHT
117 220529 SURATMAN, TN DR NENDYO, SpTHT
118 556657 VATTAHILAH SURYA PUTRA, AN DR NENDYO, SpTHT
119 228264 BUDIARTININGSIH, NY DR NENDYO, SpTHT
120 559668 GALE PUJIASTUTIK, NY DR NENDYO, SpTHT
121 120040 WINDI WULANDARI, AN DR EKACANDRA, SpKK
122 534253 DANIEL BUDI SISWANTO K, SDR DR EKACANDRA, SpKK
123 125087 ULFAWIYAH, NY DR EKACANDRA, SpKK
124 213943 ISMAWATIN, NY DR EKACANDRA, SpKK
125 555065 BAMBANG SUNARNO, TN DR OSCAR, SpM
126 555477 SAPUAH, NY DR OSCAR, SpM
127 559214 YOGI PRADANA, SDR DR OSCAR, SpM
128 121477 SAMIAN, TN DR OSCAR, SpM
LEMBAR INSUFISIENSI

KODE ICD TANDA INFORMED ASKEP CATATAN

DIAGNOSA TANGAN
SESUAI CONSENT KONSISTEN TERBACA
DOKTER
PJK + HHD 10 10 10 5 10
HHF + PJK 10 10 10 5 10
PALPITASI + ANEMIA 10 10 10 5 10
VT + GASTRITIS AKUT 10 10 10 5 0
DCF + OMI 10 10 10 5 10
IMA 10 10 10 5 0
PJK + HHF + SVT √ √ √ √ 10
PJK + EFUSI PLEURA √ √ √ √ 10
DC √ √ √ √ 10
CHEST PAIN √ √ √ √ 10
HHF √ √ √ √ 10
STEMI + HHD √ √ √ √ 10
ILUES √ √ √ √ 10
HEMOROID INTERNA √ √ √ √ 10
HIL + APENDICITIS √ √ √ √ 10
CF COSTA IX √ √ √ √ 10
RUPTURE TENDON √ √ √ √ 0
SNAKE BITE √ √ √ √ 10
ABSCES GENU √ √ √ √ 10
PERFORASI GASTER + HIL √ √ √ √ 10
COR + FR MANDIBULAR √ √ √ √ 10
GANGLION MULTIPLE √ √ √ √ 10
APENDIK PERFORASI √ √ √ √ 10
STT PUNGGUNG √ √ √ √ 10
HIL IRESPONSIBLE 10 10 10 10 5
COMBUTIO GR 2 9,5% 10 10 10 10 5
TTA 10 10 10 5 5
PERITONITIS 10 10 10 10 5
MULTIPLE LIPOMA 10 10 10 10 5
TUMOR DINDING ABDOMEN 10 10 10 10 5
CA + SEPSIS + ANEMIA √ √ √ √ 10
DHF + GASTRITIS AKUT √ √ √ √ 10
SEPSIS + GASTRITIS AKUT √ √ √ √ 10
GASTRITIS AKUT √ √ √ √ 10
DF + GASTRITIS AKUT √ √ √ √ 10
DMND √ √ √ √ 0
PJK + DC + GASTRITIS AKUT √ √ √ √ 10
GASTRITIS AKUT + ORCHITIS √ √ √ √ 10
GASTRITIS AKUT + OA √ √ √ √ 10
GASTRITIS AKUT + ISPA √ √ √ √ 10
INTOXIKASI ALKOHOL √ √ √ √ 10
GASTRITIS AKUT √ √ √ √ 10
POST SC + KPD √ √ √ √ 10
POST SC + KPD √ √ √ √ 10
POST SC √ √ √ √ 10
CURET EC AB INCOMPLETE √ √ √ √ 10
PP √ √ √ √ 10
POST SC + BSC √ √ √ √ 10
GASTRITIS AKUT √ √ √ √ 10
POST SC + KPD √ √ √ √ 10
PP + BSC √ √ √ √ 10
POST SC + POST DATE + KPD √ √ √ √ 10
GEA √ √ √ √ 10
POST SC + BSC √ √ √ √ 10
NLP ASFIKSIA √ √ √ √ 10
MORBILI √ √ √ √ 10
NA + ASFIKSIA √ √ √ √ 10
FARINGITIS AKUT √ √ √ √ 10
DF √ √ √ √ 10
NA + ASFIKSIA √ √ √ √ 10
STOMATITIS √ √ √ √ 10
FARINGITIS AKUT √ √ √ √ 10
GASTRITIS √ √ √ √ 10
FARINGITIS AKUT √ √ √ √ 10
DF √ √ √ √ 10
GEA √ √ √ √ 10
GEA + DF + BRONKITIS √ √ √ √ 10
GASTRITIS AKUT √ √ √ √ 10
MORBILI + GEA √ √ √ √ 10
ICTERUS NEONATUS √ √ √ √ 10
DM + KAD √ √ √ √ 10
DF √ √ √ √ 10
CVA INFARK + HYPNOTAREMIA √ √ √ √ 10
LBP √ √ √ √ 10
CVA INFARK √ √ √ √ 10
VERTIGO √ √ √ √ 10
CVA INFARK + TB PARU √ √ √ √ 10
CVA INFARK √ √ √ √ 10
EPILEPSI √ √ √ √ 10
DVA INFARK + HEMIPLEGI √ √ √ √ 10
CVA INFARK √ √ √ √ 10
ENCEPHALOPATY √ √ √ √ 10
STROKE ICH √ 0 √ √ 0
TTH + CRS √ √ √ √ 10
POST AFF PLATE √ √ √ √ 10
CF HUMERUS √ √ √ √ 10
CF TIBIA √ √ √ √ 0
CF CLAVICULA √ √ √ √ 10
CF RADIUS √ √ √ √ 10
CF ANTEBRACHI √ √ √ √ 10
OF FINGER √ √ √ √ 10
CF ZYGOMATICUM √ √ √ √ 10
CF PEDIS √ √ √ √ 10
CTS √ √ √ √ 10
CF CRURIS - √ √ √ 10
CF RADIUS √ √ √ √ 10
COR √ √ √ √ 10
COR √ √ √ √ 10
COR + CF ZYGOMATICUM √ √ √ √ 10
COR √ √ √ √ 10
HYDROCEPHALUS √ √ √ √ 10
COR + SCALP HEMATOM √ √ √ √ 10
COR + SCALP HEMATOM √ √ √ √ 10
COR + SCALP HEMATOM √ √ √ √ 10
COR + SCALP HEMATOM √ √ √ √ 10
COR √ √ √ √ 10
COR √ 0 √ √ 0
COR + SCALP HEMATOM √ √ √ √ 10
BATU URETER + HN √ √ √ √ 10
COLIK RENAL √ √ √ √ 10
BBB √ √ √ √ 10
NEFROLITIASIS √ √ √ √ 10
STENOSIS URETER + HN √ √ √ √ 10
TORSI TESTIS √ √ √ √ 10
DEFIASIS SEPTUM √ √ √ √ 10
OMSA + TFA √ √ √ √ 10
PERITONSIL ABSCES + DYSPHAGI √ √ √ √ 10
TFA √ √ √ √ 10
FARINGITIS + OSA √ √ √ √ 10
GEA √ √ √ √ 10
DERMATITIS ALERGI √ √ √ √ 10
VASKULARITIS √ √ √ √ 10
DRUG ERUPTION √ √ √ √ 10
DRUG ALERGI √ √ √ √ 10
ULCUS CORNEA √ √ √ √ 10
GLAUKOMA √ √ √ √ 10
HYPHEMA √ √ √ √ 10
ENDOPTHALMITIS + RUPUTRE K √ √ √ √ 10
NB: Berikan tanda (√) untuk kategori LENGKAP
Berikan tanda (-) untuk kategori TIDAK LENGKAP
 LEMBAR INSUFISIENSI

NO NORM NAMA NAMA DOKTER

1 526412 SITI KASIYAH, NY HADIQ

2 567239 JUWARIYAH, NY HADIQ
3 567164 AISYAH, NY HADIQ
4 562761 KASTUBI, TN DIAN
5 567257 SUTRISNO, TN HADIQ
6 567078 BIBIT INDAHYATI, NY INDRA
7 566634 EDDY TOBING, TN FAHMI
8 172392 PUJIONO BIN MARJU, TN INDRA
9 567248 SUPARNING, NY IWAN B
10 567007 BETTY KRISTININGRUM, BY NY BGS
11 229561 MAULYA DWI NURHVIVA, AN BGS
12 544524 GIBRAN ABBAS ASYAMIL, AN BGS
13 184023 ZAHSY AFLAH RAMADHANI, AN BGS
14 567225 SUSI ANANIS, BY NY BGS
15 567247 IVA KUSNIA DEWI, BY NY BGS
16 557823 IVA KUSNIA DEWI, NY WISNU
17 567272 RUBI`ATI, NY WISNU
18 192668 NUR KHOIYIMAH, NY WISNU
19 555590 UMI NUR AFIYAH, NY WISNU
20 560960 LILIK INDAWATI, NY WISNU
21 565276 YANTI, NY WISNU
22 562855 RENNY LESTARI, NY LINDA
23 099204 SUPARNI, NY CANDRA
24 564747 SRI SUNARTI, NY FERDI
25 039786 SUWADI, TN FERDY
26 567303 M SURYA UBAIDILLAH, TN CANDRA
27 566095 BUASAN, TN FERDY
28 567374 MISTAR, TN CHANDRA
29 126040 SRI UTAMI, NY CANDRA
30 558197 MARJONO, TN CANDRA
31 184746 MISKAN HARJO, TN ISTI
32 223310 RIKOH ARIS SETIAWAN, SDR MACHIN
33 570191 SUGENG SUGIANTO, TN ISTI
34 538922 FERA SUPARMININGSIH, NY ISTI
35 569385 SUKANDAR , TN MACHIN
36 570277 JUMANI, NY MACHIN
37 095663 LILIS INDRA NINGSIH, NY MACHIN
38 014230 SUMIATI, NY MACHIN
39 570069 LINGGOM SITUMORANG, SDR NENDYO
40 569697 LAILATUR ROHMAH, NN NEN
41 063774 SANTONO, TN NENDYO
42 566641 SUPARDI, TN NENDYO
43 230731 SUDIONO, TN NENDYO
44 570594 SLAMET CHUSEN, TN NENDYO
45 569330 AFIF SUGIANTO, TN NENDYO
46 513611 TOHALI, TN NENDYO
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
 86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
LEMBAR INSUFISIENSI

KODE ICD TANDA INFORMED ASKEP CATATAN

DIAGNOSA TANGAN
SESUAI CONSENT KONSISTEN TERBACA
DOKTER
DM+ANEMIA+GASTRITIS 10 10 10 5 10
SLE+SEPSIS+SYOK SEPSIS+TU PA 10 10 10 5 10
GASTRITIS AKUT+PJK+HIPOKALE 10 10 10 5 10
CKD+ANEMIA 10 10 10 5 0
DM+DF+GASTRITIS AKUT 10 10 10 5 10
FR COSTA 10 10 10 5 0
COR+FR MAXILLA √ √ √ √ 10
HIL √ √ √ √ 10
CORPUS ALIENUM √ √ √ √ 10
NLP + ASPEKSIA + SIB + BBLR √ √ √ √ 10
GASTRITIS √ √ √ √ 10
GEA √ √ √ √ 10
GEA √ √ √ √ 10
NA + SIB √ √ √ √ 10
EARLY ONSET √ √ √ √ 10
POST SC+POST DATE+KPD √ √ √ √ 10
HIPEREMESIS GRAVIDA+HN+BAT √ √ √ √ 0
POST RUPTUR VAGINA √ √ √ √ 10
POST SC+POST DATE+HBSAG +K √ √ √ √ 10
POST SC+BSC+KPD √ √ √ √ 10
POST SC+BSC+KPD √ √ √ √ 10
POST SC + OLIGOHYDRAMNIOS √ √ √ √ 10
BATU RENAL+CYSTITIS+HHD √ √ √ √ 10
BATU PYELUM + HN + ANEMIA √ √ √ √ 10
BATU URETER 10 10 10 10 5
KOLIK RENAL+CYSTITIS+PROSTAT 10 10 10 10 5
BPH 10 10 10 5 5
CYSTITIS+TB PARU+CAP+SEPSIS 10 10 10 10 5
COLIC RENAL+ ISK 10 10 10 10 5
BATU URETER+ HN+ SEPSIS+ C 10 10 10 10 5
HHD + TB PARU + HEMIPARASE P √ √ √ √ 10
ENCHEPALITIS √ √ √ √ 10
VERTIGO √ √ √ √ 10
GBS √ √ √ √ 10
CVA INFARK √ √ √ √ 10
LBP √ √ √ √ 0
TTH + MYALGIA √ √ √ √ 10
HNP √ √ √ √ 10
TONSILITIS √ √ √ √ 10
TUMOR AURICLE √ √ √ √ 10
EPITAXIS √ √ √ √ 10
CA MAXILLA+SEPSIS √ √ √ √ 10
EPITAXIS √ √ √ √ 10
TUMOR TONSIL √ √ √ √ 10
SINUSITIS KRONIS √ √ √ √ 10
SINISTIS KRONIK √ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ 0 √ √ 0
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 0
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
- √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ 0 √ √ 0
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
√ √ √ √ 10
NB: Berikan tanda (√) untuk kategori LENGKAP
Berikan tanda (-) untuk kategori TIDAK LENGKAP
 LEMBAR INSUFISIENSI JANUARI - MARET 2019
TANDA SIMBOL &
KODE ICD SESUAI TANGAN INFORMED ASKEP CATATAN
NO NORM NAMA NAMA DOKTER DIAGNOSA SINGKATA
YA TIDAK DOKTER CONSENT KONSISTEN TERBACA N
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NB: Berikan tanda (√) untuk kategori LENGKAP
Berikan tanda (-) untuk kategori TIDAK LENGKAP