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  • Clinical Pathway Rsu Kumala Siwi Mijen Kudus

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    Ajeng Saranghage Momy
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    This clinical pathway document outlines the treatment plan for a patient diagnosed with bronchopneumonia over a planned 6 day hospital stay. It includes the patient's details, diagnosis, assessments, medical tests, treatments, medications, outcomes, education and discharge planning. Fields are included to track the patient's status and care received on each day of their hospitalization.

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    Clinical Pathway BRPN

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    This clinical pathway document outlines the treatment plan for a patient diagnosed with bronchopneumonia over a planned 6 day hospital stay. It includes the patient's details, diagnosis, assessments, medical tests, treatments, medications, outcomes, education and discharge planning. Fields are included to track the patient's status and care received on each day of their hospitalization.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    17 views2 pages

    Clinical Pathway Rsu Kumala Siwi Mijen Kudus

    Uploaded by

    Ajeng Saranghage Momy
    This clinical pathway document outlines the treatment plan for a patient diagnosed with bronchopneumonia over a planned 6 day hospital stay. It includes the patient's details, diagnosis, assessments, medical tests, treatments, medications, outcomes, education and discharge planning. Fields are included to track the patient's status and care received on each day of their hospitalization.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    of 2

    CLINICAL PATHWAY

    RSU KUMALA SIWI MIJEN KUDUS

    BRONKOPNEUMONIA
    Nama Pasien: Umur: Berat Badan: Tinggi Badan: Nomor Rekam Medis:
    …………………………………………………… ……………… ……………..kg …………..cm …………………………….
    Diagnosis Awal: Bronkopneumonia Kode ICD 10 : …………………… Rencana rawat : …. hari
    R. Rawat Tgl/Jam masuk: Tgl/Jam keluar: Lama Rwt Kelas: Tarif/hr (Rp): Biaya (Rp)
    Aktivitas Pelayanan ……………. ………………. ………………. ……... hari …….. …………. ……………
    Hari Rawat 1 Hari Rawat 2 Hari Rawat 3 Hari Rawat 4 Hari Rawat 5 Hari Rawat 6
    Hari Sakit: … Hari Sakit: … Hari Sakit: … Hari Sakit: … Hari Sakit: … Hari Sakit: …
    Diagnosis:
     Penyakit Utama Bronkopneumonia
     Penyakit Penyerta

     Komplikasi …………. …………. …………. …………. ………….


    …………. …………. …………. …………. ………….
    …………. …………. ……….... …………. ………….

    Asesmen Klinis:
     Pemeriksaan dokter + / - + / - + / - + / - + / - …………..
     Konsultasi
    ………… ………… …………. …………. ……….. …………..
    Pemeriksaan Penunjang:
     He + / - + / - + / - + / - + / - …………..
    moglobin + / - + / - + / - + / - + / - ……………
     Ht + / - + / - + / - + / - + / - ……………
     Le + / - + / - + / - + / - + / - ……………
    ukosit + / - + / - + / - + / - + / - ……………
     Tr
    + / - + / - + / - + / - + / - ……………
    ombosit
     LE + / - + / - + / - + / - + / -
    D
     Ro
    toraks PA
     BT
    A sputum
     EK
    G
    Tindakan:
    *Oksigen *Oksigen *Oksigen *Pasang *Pasang …………..
    *Pasang *Pasang *Pasang IVFD IVFD ……………
    IVFD IVFD IVFD ……………
    *Terapi *Terapi *Terapi
    Inhalasi Inhalasi Inhalasi

    30
    Obat Obatan:
    - Inj Ceftriaxone / + / - + / - + / - + / - + / - …………..
    cefotaxime 2x1 g + / - + / - + / - + / - + / - ……………
    - Mukolitik + / - + / - + / - + / - + / - ……………
    - Antipiretik + / - + / - + / - + / - + / - ……………
    ………………………….
    …………………………..
    ………………………….

    Nutrisi: biasa/ lunak/ cair ………..... ...……….. …………. …………. ………… ……………
    Mobilisasi:: …………. …………. …………. …………. ………… ……………

    Hasil (Outcome):
     Kesadaran …………. …………. …………. …………. ………….
     Febris + / - + / - + / - + / - + / -
     Sesak napas + / - + / - + / - + / - + / -
    Pendidikan/Rencana
    Pemulangan:
     Pe + / - + / - + / - + / - + / -
    njelasan penyakit + / - + / - + / - + / - + / -
     Gi + / - + / - + / - + / - + / -
    zi
     Ko
    ntrol poliklinik
    Varians: ………… ………… ………… ………… …………
    …………. …………. …………. …………. ………….
    ………… ………… ………… ………… …………
    ………… ………… ………… ………… …………
    Jumlah Biaya …………..
    Diagnosis Akhir: Kode ICD 10 Jenis Tindakan: Kode ICD 9 – CM
    Perawat (PPJP)
    ……………………

     Utama Bronkopneumonia  Visite/Konsul: Anamnesis & PF 89.0 dan 89.7


    DPJP:  Penyerta ……………………… ………..  Pemeriksaan mikroskop darah 90.5
    ....................... ………………………. ………..  Foto toraks PA 87.44
    ……………………… ………..  Pemasangan IVFD & Inj. obat 99.2
     Komplikasi ……………………… ………..  Oksigen 93.96
    Verifikator
    …………………..

    31

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