Kamis, 28 Maret 2019 RAH/DAN/DBI/PER/WID/API/RIC/(SIW)
RUANG BED PJ DPJP NAMA U MRS DIAGNOSIS STATUS PLAN BIAYA LAB K PER AM Archi Raka 6 2/3 Post medikasi & non-excicional debridement ai. Post op Perawatan post op BPJS I 2/3 alb 2,9 na 130 k 3,7 cl 102 ca 1,19 01452094 Combusio gr.II 40% 3/3, 6/3, Yang sudah epitelisasi rawat terbuka RGB 8/3, 11/3, Rencana Op KAMIS 28/3/19 14/3, 18/3, 21/3, 25/3 Kabini 62 15/3 Post rekonstruksi mandibula a/I SCC intraoral Post-op Perawatan post op BPJS III 15/3 hb 9,9 ht 29 leu 9,9 tro 310 hbsag NR 3 RIC DE 01450014 konsulan 26/3 onko ICU Miftahuddi 26 Konsulan Post scalp transposition flap + STSG a/I Wound Post-op Perawatan post op BPJS II 8/3 hb 13,3 ht 46 leu 12,9 tro 354 hbsag NR 7 WID AM n B.Saraf dehisens & skull defect R.frontotemporal 22/3 Rawat STSG/5 hari, medikasi bila kasa keruh 01392435 12/3 601 A WID AM Parwono 51 26/3 Fistel post rekonstruksi mandibula, post Pre op Pro Revisi. BPJS II - hemimandibulektomi a/I SCC mandibula Cek lab ikterik 602 A WID Sudarmi Konsulan B.Onk: Basal cell carcinoma R.zygoma (D) + Pre-op B.Onk: Pro wide excisi 01451450 onko 20/3 extend orbita (D) 602 D WID DE Juwati 71 Konsulan SCC intra oral (join op) Pre op Tanya ketersediaan bone graft, costocondral BPJS II 10/3 hb 11,1 ht 36 leu 5,6 tro 243 alb 4,2 hbsag NR 01448008 Onko 10/3 Anemia graft,konfirmasi dr.Galuh,SpBPRE 604 A WID DE MasCuk 49 23/3 BS (leader, lepas rawat): COR Pre-op BS: konservatif, alih leader ke OT UMUM II 23/3 hbsag NR 01454652 OT (leader): CF clavicula 1/3 tengah (S) Allman I OT: ORIF elektif BP: maloklusi, fr.parasimfisis mandibula (S), BP: diit cair, oral hygiene, urgent fr.dislokasi condyle(S),vulnus terjahit r.frontal (S) Reconstruction of mandible, Other repair & [Maloklusi, fr.of mandible, multiple open wound reconstruction of skin & subcutaneous tissue of head] 608 C WID AM Imron 56 27/3 BP: Fr.NOE, fr.rima orbita lateral (D), fr maxilla Pre-Op BP: ORIF elektif. Maxilla + NOE = adaption BPJS II 26/3 hb 16,3 ht 45 leu 13,6 tro 271 FL 6 Djamil (D) fr.ramus (D) mandibula plate. Rima orbita = orbita plate. Mandibula 01455117 OT: CF tibia = mandibular plate + arch barr. BS: COR OT: ORIF elektif BS: Konservatif 611 B WID DE Dwi Cahyo 31 24/3 Post medikasi + NPWT a/I Raw surface R.cruris Post-op Perawatan post op Jamsostek - 01452439 (D) II 612 A WID AM Sutarno 443 15/3 Post debridement cito a/i/ vulnus berbentuk flap Post op Perawatan post op, pesan PICO Jamsostek I - 01453677 R. pedis (S) 15/3, 25/3 612 B WID DE Alfadite 30 19/3 BP: Maloclusion, fr.of malar & maxillar bone Pre-op BP: other recinstruction of other facial bone, BPJS I 01454089 open. (fr. Proc alveolaris maxilla, fr. Palatum) openreduction of maxillary fr., oral hygiene, UMUM OT: CF distal radius D & S diit cair. MMF + arch barr bila OT op (skrg) OT: ORIF elektif 613 B WID DE Januar 23 19/3 BP: Post ORIF a/I fr. Mandibula Post-op BP: diit cair, oral hygiene BPJS I 19/3 hb 15,9 ht 47 leu 15,8 tro 187 hbsag NR 01454075 OT: CF metacarpal 2-3 manus S, CF clavicula S POLIKLINIS 902 B RIC DE Sukamto 37 18/3 NPWT a/I Vulnus granulosum Pre-op Kultur ulang. Medikasi, ganti dressing. AB BPJS III - 00936200 sesuai kultur, tabur ke luka Graft rencana KAMIS 28/3 902 C RIC DE Aguk Dwi 35 17/3 Post ORIF a/I Fr.corpus mandibula (D) Post-op Perawatan post op BPJS III - Guntoro 01453408 903 C RIC DE Wahono 23 5/3 Post debridement, fasciotomi, medikasi a/I Post op Perawatan post op UMUM 5/3 hb 16,9 ht 52 leu 12,5 tro 385 alb 5,5 hbsag NR 01452441 Combutio listrik gr.II-III 38,5% & Sindrom 5/3, 12/3, Medikasi light dressing. BLPL, pasang spalk Kompartemen 19/3, 26/3 kedua tangan, rawat tulle +burnazin 904 B PER DE Siswanto 68 19/3 BS:COR E4V5M6 Pre-op BS: konservatif BPJS 18/3 hb 10,2 ht 31, leu 17,3 tro 208 hbsag NR 01454049 BP: Susp Fr.Maxilla (D), multiple vulnus terjahit BP: MMF + arch barr bila OT op R.frontal, vulnus apertum R.labia oris sup, R.manus (D), vulnus terjahit R.genu (D) Susp fr.genu 904 D RIC AM Alip Budi 27 22/3 Post tutup defek a/I Raw surface R. occipital + Post-op Perawatan post op BPJS III - FL 9 01449960 bone expose 904 E RIC AM Sariyono 61 10/3 Post debridement + ekstensi lengan + slab a/i Post-op Perawatan post op, medikasi/hari BPJS III - 01449915 Vulnus granulosum R.antebrachii (S) post snake 12/3, 15/3 Saat medikasi slab tetap terpasang bite grade II Medikasi + Mebo foto klinis 905 B RIC AM Kusniyati 30 24/3 Kontraktur R.manus (S), riw release kontraktur Pre-op Ro manus ap/oblique, rencana konsul ortho BPJS 01412624 [Contracture of muscle hand] 906 D RIC AM Putri Ayu 20 24/3 Post palatoplasty a/I Palatoschizis Post-op Perawatan post op BPJS III - 01450600 906 E RIC AM Tiara 17 15/3 Post repair vulnus a/I Vulnus + ORIF a/I fr. Nasal Post-op Oral hygiene, diit cair, perawatan post op UMUM 01453562 + fr. Rima orbita 19/3, 25/3 Evaluasi luka, BLPL hari ini 907 A RIC DE Wagimin 46 11/3 Neurofibroma Post op Perawatan post op BPJS III - 01450529 BLPL 908 B RIC AM Deni Fitriya 18 26/3 Vulnus apertum r.calcaneus Post op Cito debridement +repair vulnus Kerja sama - 01449692 III 908 C RIC AM Asep 33 15/3 BP: Post ORIF Arch zygoma + rima orbita Post-op BP:Perawtan post op, penyerahan ke OT BPJS - Sopiyan OT: CF tibia OT: ORIF elektif BS: COR BS: Konservatif BD: post laparotomi ec peritonitis BD: perawatan post op 908 E RIC AM Kuwati 64 27/3 Snake bite gr. I pedis (D) Pre-op Konservatif BPJS III - 01455187 (Alergi Penicillin) Cek PT/APTT 24 jam 910 A RIC AM Prasetyo 6 24/3 Post aff hecting + regrafting a/I Kontraktur R.colli, Post-op Perawatan post op BPJS III - Hendri P. post release kontraktur R.colli 01395379 910 D RIC DE Hari 13 22/3 BP: Fr. Maxilla (D)&(S), fr. Rima orbita inf (D)&(S), Pre-op BP: ORIF elektif, diit cair, oral hygiene BPJS 22/3 hb 14,0 ht 41 leu 27,1 tro 356, hbsag NR Supriyanto fr. rima orbita sup (S), fr. Arch zygoma (D), multiple Grouping: open reduction of mallar 01454616 Vulnus excoriasi zygomatic fr., open reduction of maxillary fr. Grouping: fr. Orbital floor, fr.of malar & maxillary bone, multiple open wound of head BS: konservatif BS: COR E3V55M6, EDH, SDH, udem cerebri, pneumotocele 1002 A RIC AM Suryanto 55 18/8 Post wide eksisi + frozen section a/I Basal cell Post-op Perawatan post op BPJS III - 01449778 konsulan carcinoma R.maxilla (D) Evaluasi kornea, benang jahitan dekat mata onko potong pendek. Aff drain handscoon 1002 B RIC DE Dwi Suseno 28 19/3 B.Onk: Post Hemimandibulektomy a/I Post-op Perawatan post op BPJS III 01449086 konsulan ameloblastoma R. mandibula (D) onko 1005 B RIC AM Suwarni 41 24/3 Post medikasi + skin graft a/I Vulnus granulosum Post-op Perawatan post op BPJS III - 01454435 1009 B RIC AM Maryanto 40 20/3 BS: COR, udem cerebri, SDH Pre-op BS: konservatif, penyerahan ke plastik BPJS 20/3 hb 17,1 ht 53 leu 16,4 tro 232 hbsag NR 01021474 BP (leader): fr.condyle mandibula (D) BP: pro ORIF KJ: gangguan afektif bipolar KJ: Tx farmaka & psikoedukasi 1011 C API DE Sutarno 42 18/3 BS: COS E3V3M5, udem cerebri Post op BS: Konservatif 18/3 hb 12,1 ht 37 leu 18,7 tro 346 01453978 BP: maloklusi, fr.tripod, ruptur duct nasolacrimalis, 19/3 BP: Oral hygiene, diit cair, ORIF elektif, cito FL. 10 vulnus apertum R.palpebra inferior debridement + repair vulnus + repair ductus nasolacrimalis 1011 E RIC DE Arie Basuki 36 25/3 BP: Fr. Rima orbita sup (D), fr. Maxilla (S) Pre-op BS: konservatif Jasa 24/3 hb 13,1 ht 39 leu 9,7 tro 180 hbsag NR 01454748 BS: COR E3V5M6 BP: ORIF elektif, diit cair, oral hygiene Raharja 1012 A API DE Agung T. 17 20/3 BS: COR, udem cerebri Post-op BS: konservatif BPJS - 01454350 BP: Post ORIF a/I Fr. Rima orbita inf (D) extend to BP: perawatan post op zygoma (D) & maxilla (D), multiple VE 1013 A RIC DE Atmo 73 23/3 BS (Leader, lepas rawat): COR Pre-op BS: penyerahan ke Plastik UMUM III 22/3 hb 11,4 ht 35 leu 15,9 tro 296 hbsag NR 01454629 BTKV: Pneumothorax, post tube thoracostomy BTKV: perawatan post op BP: fr.arch zygoma (S), multiple excoriasi BP: diit cair, oral hygiene, open reduction of R.facialis, vulnus terjahit R.supraciliar (S) mallar & zygomatic fr., debridement. Rawat [Fr.of mallar & maxillary bone, multiple open luka dengan MEBO wound of head] IGD