FORMULIR ANALISIS KUANTITATIF B

RSUD RA

A NO. RM NAMA NAMA DOKTER DPJP

TANGGAL MASUK TANGGAL KELUAR

1 199575 BUCHARY USMAN dr. Budi, Sp.B

2 332050 WILIAN CHIKO 5/5/2022 5/9/2022 dr. Hari, Sp.B
3 332980 MUHAMMAD H 5/25/2022 5/28/2022 dr. T. Mira. Sp.PD
4 252585 MUCTAR RITO 5/24/2022 5/25/2022 dr. Arif, Sp.S
5 112556 SITI FATIMAH 5/12/2022 5/14/2022 dr. Dedy Shauqi, Fs.m.
6 332857 SYAWALUDDI 5/24/2022 5/26/2022 dr. Arif, Sp.S
7 263966 ATUR MIRSA 5/13/2022 5/14/2022 dr. Guntur Ginting, Sp.
8 332694 BOIMIN 5/19/2022 5/23/2022 dr. Dedy Shauqi, Fs.m.
9 298437 MAIMUNAH 5/12/2022 5/13/2022 dr. Humberto, Sp.THT-
10 138735 NURAYATI 5/25/2022 5/26/2022 dr. Windi, Sp.OT
11 91125 DAHLIA 5/17/2022 5/17/2022 dr. Arif, Sp.S
12 332422 SUMARNI 5/13/2022 5/19/2022 dr. M. Fadhly Sigalingging
13 211426 SUMARNO 5/17/2022 5/18/2022 dr. Budi, Sp.B
14 224240 RASIDEN 5/22/2022 5/25/2022 dr. Ayuhati S , M.Ked(PD)
15 332482 ERNAWATI TAMP 5/17/2022 5/19/2022 dr. Budi, Sp.B
16 332704 BUHA PAUL 5/20/2022 5/21/2022 dr. Rachmad Meyliandry Pu
17 332249 INTAN KOMALA JU 5/10/2022 5/18/2022 dr. Windi, Sp.OT
18 332095 M AZHAR TANJUN 5/8/2022 5/11/2022 dr. Hari, Sp.B
19 115043 NURBUNGA RAMA 5/23/2022 5/24/2022 dr. Budi, Sp.B
20 327530 ALANG SYAFII 5/19/2022 5/20/2022 dr. Windi, Sp.OT
21 332554 DR IRWAN EFENDI 5/17/2022 5/18/2022 dr. Arif, Sp.S
22 332596 ROSELLY SITUMO 5/23/2022 5/24/2022 dr. Budi, Sp.B
23 181705 RISKA BERLIAN 5/8/2022 5/9/2022 dr. Reza, Sp.B
24 332000 FAZRI 5/18/2022 5/19/2022 dr. Arif, Sp.S
25 332865 MURTI HASIBUAN 5/24/2022 5/15/2022 dr. Budi, Sp.B
26 289319 NURWATI MUNTH 5/8/2022 5/9/2022 dr. Farida, Sp.JP
27 289094 RIFAN 5/12/2022 5/13/2022 dr. Windi, Sp.OT
28 289029 M IBNU HARUS SI 5/3/2022 5/6/2022 dr. Guntur Ginting, Sp.PD
29 288455 IWARIDA HASIBUA 5/25/2022 5/27/2022 dr. Rachmad Meyliandry Pu
30 287239 MARISA FADILLAH` 5/10/2022 5/13/2022 dr. Guntur Ginting, Sp.PD
31 286977 ASRIN MUNTHE 5/19/2022 5/22/2022 dr. Kartika, Sp.JP
32 285490 NORMAWATI 5/17/2022 5/19/2022 dr. Arif, Sp.S
33 280759 SITI AMNAH S 5/5/2022 5/9/2022 dr. Guntur Ginting, Sp.PD
34 170899 MASLIYAH 5/28/2022 5/30/2022 dr. Artisya Fajriani, M.Ked,
35 171469 M SAIB HARAHAP 4/28/2022 5/1/2022 dr. Rachmad Meyliandry Pu
36 172607 TUTY IRAWANI 5/25/2022 5/30/2022 dr. T Mira, Sp.PD
37 173388 FAUZIAH HANUM 5/26/2022 5/30/2022 dr. T Mira, Sp.PD
38 178108 SUKAMTO 5/10/2022 5/13/2022 dr. Guntur Ginting, Sp.PD
39 178704 KHAIRANI 5/22/2022 5/25/2022 dr. Ayuhati S , M.Ked(PD)
40 260104 HALOMOAN SAING 5/9/2022 5/12/2022 dr. Novriyanti, Sp.PD
41 260329 WAN SITI MAANI 5/11/2022 5/13/2022 dr. T Mira, Sp.PD
42 260512 NURHASANAH NAS 5/20/2022 5/23/2022 dr. Artisya Fajriani, M.Ked,
43 260605 RIA ZANUM LUBIS 5/23/2022 5/27/2022 dr. H Ainal, Sp.OG
44 261038 SYAHRUM TAMBU 5/23/2022 5/19/2022 dr. Farida, Sp.JP
45 261317 AZKA ALDRIC ADE 5/18/2022 5/19/2022 dr. Rachmad Meyliandry Pu
46 262052 DORA SITOHANH 5/23/2022 5/24/2022 dr. Arif, Sp.S
47 262224 SAPARUDDIN SIM 5/28/2022 5/30/2022 dr. Farida, Sp.JP
48 262838 MUJIMAN 5/12/2022 5/14/2022 dr. Dedy Shauqi, Fs.m.Ked
49 263006 ALI WAHYUDI 5/20/2022 5/21/2022 dr. M. Fadhly Sigalingging
50 263213 SADI'AH 5/11/2022 5/17/2022 dr. H Ainal, Sp.OG

1 334471 LHUTFIA KHAIRINN 6/24/2022 6/28/2022 dr. Hari, Sp.B

2 334449 YOGA ARYA PRAT 6/23/2022 6/24/2022 dr. Windi, Sp.OT
3 334611 NURSANI MATON 6/27/2022 6/30/2022 dr. Budi, Sp.S
4 334452 MAHALEN 6/24/2022 6/30/2022 dr. Fransisco Pkpahan, M.
5 334063 MUSLIMAH 6/16/2022 6/19/2022 dr. Tun Ali. Sp.OG
 6 334620 RIKY 6/28/2022 6/29/2022 Dr. Rachmad M Putra, Sp.
7 333546 HERLINA AGUSTIN 6/7/2022 6/11/2022 dr. H Ainal, Sp.OG
8 333992 DHEA ANANDA HA 6/15/2022 6/16/2022 dr. H Tun Ali, Sp.OG
9 333258 JUJUR PARNINGOT 6/1/2022 6/4/2022 dr. Sri Damayana, Sp.OG
10 333604 YURNIA WATI ZEG 6/8/2022 6/10/2022 dr. Ainal, Sp.OG
S KUANTITATIF BERKAS REKAM MEDIS PASIEN RAWAT INAP
RSUD RANTAUPRAPAT

UMUM MEDIS TENAGA KESEHATAN LAIN OPERASI

Pemberian Informasi dan Edukasi Pasien/Keluarga Terintegrasi
Identitas Pasien ( Lembar Masuk dan Keluar )

Catatan Perkembangan Terintegrasi Di Ruangan

Surat Persetujuan Tindakan Kedokteran

Surat Penolakan Tindakan Kedokteran

Catatan Pemberian Obat Tepat Waktu

Asesmen Awal Medis Rawat Inap

Persetujuan Tindakan Kedokteran

Pengkajian Pasien Gawat Darurat

Formulir Konsultasi Rawat Inap

Persetujuan Tindakan Anastesi

Resume Medis Rawat Inap

Surat konsultasi / Rujuk

Resume Keperawatan

Rehalibitas Medik
General Concent

Dan Lain - Lain

Perawat

Farmasi
Dokter
Bidan
Gizi

X ✓ X X X - X X - X X X - ✓ ✓ - - - - - X X
X X X X ✓ ✓ ✓ X ✓ X ✓ X - ✓ ✓ - - - - - ✓ X
X ✓ X X X - X X X X ✓ X - ✓ ✓ - - - - - X -
✓ X ✓ X - - X X X X - X - ✓ ✓ - - - - - - -
✓ ✓ X X - - ✓ X X X X X - ✓ ✓ - ✓ ✓ - - - -
✓ X X X - - ✓ X X X - X - ✓ ✓ - - - - - - -
✓ ✓ ✓ X ✓ - ✓ X X X - X - ✓ ✓ - - - - - - -
X ✓ ✓ X X ✓ X X X X ✓ X - ✓ ✓ - - - - - X -
✓ ✓ X X - - - X X X - ✓ - ✓ ✓ - ✓ - - - - -
X ✓ X X X - ✓ X X X - - - ✓ ✓ - - - - - X -
X ✓ X X - - ✓ X ✓ X - ✓ - ✓ ✓ - - - - - X -
X ✓ ✓ X ✓ - ✓ X X X ✓ ✓ - ✓ ✓ - - - - - ✓ X
✓ ✓ ✓ X ✓ - ✓ X X X - ✓ - ✓ ✓ - - - - - ✓ -
✓ ✓ ✓ ✓ - - ✓ ✓ X ✓ - ✓ - ✓ ✓ - ✓ - - - - -
X ✓ ✓ ✓ ✓ - ✓ X X ✓ ✓ ✓ ✓ ✓ ✓ - - - - - ✓ ✓
✓ ✓ X ✓ ✓ - ✓ X X X - ✓ - ✓ ✓ - - - - - ✓ -
✓ ✓ ✓ ✓ X - ✓ X - X ✓ ✓ - ✓ ✓ - - - - - X ✓
✓ ✓ ✓ ✓ ✓ - ✓ X ✓ X ✓ ✓ - ✓ ✓ - - - - - ✓ -
✓ ✓ ✓ X ✓ - ✓ X ✓ X - ✓ - ✓ ✓ - - - - - ✓ -
✓ ✓ X ✓ ✓ - ✓ X ✓ ✓ X
X - ✓ ✓ - - - - - ✓ X
✓ ✓ X ✓ - - X ✓ ✓ - ✓
X - ✓ ✓ X X X X X - -
X ✓ - ✓ ✓ - X ✓ ✓ - ✓
X - ✓ ✓ - - - - - ✓ -
✓ ✓ X X ✓ - ✓ ✓ X - X
X - ✓ ✓ - - - - - ✓ -
✓ ✓ ✓ X - - ✓ ✓ x ✓ ✓
X - ✓ ✓ X X X X X - -
✓ ✓ X ✓ X - ✓ ✓ ✓ - ✓
X - ✓ ✓ - - - - - - -
✓ ✓ X ✓ - - ✓ ✓ ✓ X ✓ ✓ - ✓ ✓ - - - - - - -
✓ ✓ ✓ ✓ - - ✓ X X x - ✓ - ✓ ✓ - - - - - - -
X ✓ ✓ X - - ✓ X X X ✓ ✓ - ✓ ✓ - - - - - - -
✓ ✓ X X ✓ - ✓ X X X ✓ X - ✓ ✓ - - - - - ✓ X
✓ ✓ ✓ ✓ - - ✓ X X X ✓ ✓ - ✓ ✓ - ✓ ✓ - - - -
✓ ✓ X X - - X X ✓ X - ✓ - ✓ ✓ - - - - - - -
X ✓ X X - - ✓ X X X - X - ✓ ✓ - - ✓ - - - -
✓ ✓ ✓ X - - X X X X - ✓ - ✓ ✓ - - ✓ - - - -
✓ ✓ X X - - ✓ ✓ X X - ✓ - ✓ ✓ - - - - - - -
✓ ✓ ✓ X ✓ - ✓ X - X ✓ X - ✓ ✓ - - - - - ✓ ✓
✓ ✓ ✓ X - - X ✓ X X ✓ ✓ - ✓ ✓ - - - - - - -
✓ ✓ X - - ✓ X X X - ✓ - ✓ ✓ - - - - - - -
✓ ✓ X X - - ✓ X ✓ X - ✓ - ✓ ✓ - - - - - - -
✓ ✓ X X - - X ✓ X X - ✓ - ✓ ✓ - - - - - - -
X ✓ X X - - ✓ ✓ X X - X - ✓ ✓ - - - - - - -
✓ ✓ X ✓ - - ✓ ✓ - X ✓ ✓ - ✓ ✓ - - ✓ - - - -
X ✓ X X - - ✓ ✓ X X - ✓ - ✓ ✓ - - ✓ - - - -
✓ ✓ X X ✓ - - X ✓ X X X - ✓ ✓ - - - - - ✓ ✓
✓ ✓ X X - - ✓ X X X - ✓ - ✓ ✓ - ✓ - - - - -
✓ ✓ ✓ X ✓ - ✓ X ✓ X - X - ✓ ✓ - - - - - ✓ -
✓ ✓ X X - - - X X X - X - ✓ ✓ - - - - - - -
✓ ✓ X X - - ✓ X X X - X - ✓ ✓ - - ✓ - - - -
✓ ✓ X X - - X X ✓ X - ✓ - ✓ ✓ - - - - - - -
✓ ✓ X X - - ✓ X X X - X - ✓ ✓ - - - - - - -
✓ ✓ ✓ X - - - X X X - X - ✓ ✓ - - - - - X ✓

X ✓ X X - - X X X ✓ - X - ✓ ✓ - - - - - - -
✓ ✓ X X - - ✓ X ✓ X - X - ✓ ✓ - - - - - - -
✓ ✓ X X ✓ - ✓ X X X ✓ X - ✓ ✓ - - - - - ✓ -
✓ ✓ X X - - X X X X X X - ✓ ✓ - - - - - - -
✓ ✓ X X ✓ - - ✓ ✓ ✓ ✓ X - - ✓ ✓ - - - - ✓ ✓
X ✓ X ✓
X - ✓ X X X - X - ✓ ✓ - - - - - ✓ -
✓ ✓ X ✓
X - - X ✓ ✓ X ✓ - - ✓ ✓ - - - - ✓ ✓
X ✓ X -
X - - X ✓ X - ✓ - - ✓ ✓ - - - - - -
X ✓ ✓ X ✓ - - X ✓ X ✓ X - ✓ ✓ - - - - - ✓ ✓
X ✓ X X - - - X X ✓ - X - - ✓ ✓ - - - - - -
 Tanggal :

KELENGKAPAN SETELAH DIPERIKSA

OPERASI LAIN - LAIN
Checklist Keselamatan Pasien Operasi

Formulir Perawatan Pasca Bedah

Pulang Atas Permintaan Sendiri

Surat Keterangan Kematian

TIDAK LENGKAP (TD)

Surat Permintaan Visum
Surat Keterangan Lahir

(L)
Tanggal Lahir/Umur

TIDAK TERBACA
No. Rekam Medis
Laporan Operasi
Status Anestesia

Transfer Pasien

Nama Pasien

TERBACA
LENGKAP

✓ ✓ X X X - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ X X X - - - - ✓ ✓ ✓ ✓ - ✓ -
X ✓ - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ - ✓ ✓ -
- - - - X - - - - ✓ ✓ ✓ - ✓ ✓ -
- - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ - - X - - - - ✓ ✓ ✓ - ✓ -
- - - - - - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ - ✓ ✓ -
✓ ✓ - - X - - - - ✓ ✓ ✓ - ✓ ✓ -
✓ ✓ - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ X X X - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ ✓ X X - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ - - X - - - - ✓ ✓ ✓ - ✓ ✓ -
✓ ✓ - - - - - - - ✓ ✓ ✓ - ✓ ✓ -
✓ ✓ ✓ X X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ - - ✓ - - - - ✓ ✓ ✓ - ✓ ✓ -
✓ ✓ - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - ✓ - - - - ✓ ✓ ✓ - ✓ ✓ -
- - - - X - - - - ✓ ✓ ✓ - ✓ ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ ✓ ✓ X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - - - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ ✓ X X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - ✓ - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ - ✓ ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ ✓ X - - ✓ - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X ✓ - - - ✓ ✓ ✓ ✓ - ✓ -
✓ X - - - - - - - ✓ ✓ ✓ - ✓ ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - ✓ - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ X ✓ - - - ✓ - - ✓ ✓ ✓ ✓ - ✓ -

- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - ✓ - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ - - X X - - - ✓ ✓ ✓ ✓ - ✓ -
- - - - X - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ X ✓ ✓ - - ✓ - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ - - ✓ - - - - ✓ ✓ ✓ ✓ - ✓ -
X ✓ ✓ ✓ - - ✓ - - ✓ ✓ ✓ ✓ - ✓ -
- ✓ - - - - - - - ✓ ✓ ✓ ✓ - ✓ -
✓ ✓ ✓ X - - ✓ - - ✓ ✓ ✓ ✓ - ✓ -
- - - - - - - - - ✓ ✓ ✓ ✓ - ✓ -
IPERIKSA
DIKIRIM 2 x 24 JAM

✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓

✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
 UMUM

Pemberian Informasi dan Edukasi Pasien/Keluarga Terintegrasi

Identitas Pasien ( Lembar Masuk dan Keluar )

Surat Persetujuan Tindakan Kedokteran

Surat Penolakan Tindakan Kedokteran

Asesmen Awal Medis Rawat Inap

Pengkajian Pasien Gawat Darurat

General Concent
A NO. RM NAMA NAMA DOKTER DPJP
TANGGAL MATANGGAL KE

1 334471 LHUTFIA K 6/24/2022 6/28/2022 dr. Hari, SpX ✓ X X - - X

2 334449 YOGA ARYA 6/23/2022 6/24/2022 dr. Windi, ✓ ✓ X X - - ✓
3 334611 NURSANI 6/27/2022 6/30/2022 dr. Budi, Sp✓ ✓ X X ✓ - ✓
4 334452 MAHALEN 6/24/2022 6/30/2022 dr. Fransisco Pkpahan, M.Ked(ParX
5
6
7
8
9
10
 X
X
X
Resume Medis Rawat Inap

X
X
✓
Resume Keperawatan

X
X
✓
Catatan Perkembangan Terintegrasi Di Ruangan

-
-

✓
MEDIS

Formulir Konsultasi Rawat Inap

X
X
X

X
Catatan Pemberian Obat Tepat Waktu

-
-
-
-
Surat konsultasi / Rujuk

✓
✓
✓
✓
Perawat

✓
✓
✓
✓

Dokter
-
-
-
-

Bidan
-
-
-
-

Gizi
-
-
-
-

Farmasi
-
-
-
-
TENAGA KESEHATAN LAIN

Rehalibitas Medik
-
-
-
-

Dan Lain - Lain

 -
-

✓
Persetujuan Tindakan Kedokteran

-
-
-
Persetujuan Tindakan Anastesi

-
-

✓
Checklist Keselamatan Pasien Operasi

-
-

✓
OPERASI

Laporan Operasi

-
-
-
Status Anestesia

-
-
-
Formulir Perawatan Pasca Bedah

X
X
✓
Transfer Pasien

-
-

X
Pulang Atas Permintaan Sendiri
-
-
-

Surat Keterangan Lahir

-
-
-

Surat Keterangan Kematian

-
-
-

Surat Permintaan Visum

LAIN - LAIN

✓
✓
✓

Nama Pasien
✓
✓
✓

No. Rekam Medis

✓
✓
✓
Tanggal Lahir/Umur

✓
✓
✓
LENGKAP (L)

-
-
-
TIDAK LENGKAP (TD)

✓
✓
✓
TERBACA

-
-
-
TIDAK TERBACA

✓
✓
✓
KELENGKAPAN SETELAH DIPERIKSA

DIKIRIM 2 x 24 JAM
A NO. RM NAMA
TANGGAL MATANGGAL KELUA

1 084399 ERNAWATI8/6/2022 10/10/2022

2 264877 YANTI SUS 8/10/2022 29/10/2022
3 261609 ANNISA KH3/10/2022 5/10/2022
4 334501 ROTAMA J 4/10/2022 5/10/2022
5 304306 MORA AMRI
29/9/2022 3/10/2022
6 352588 RAFIQ FAR29/9/2022 1/10/2022
7 352918 BARRERRA5/10/2022 6/10/2022
8 198815 IRNA KHAI 17/10/2022 20/10/2022
9 270363 MUSA 28/9/2022 3/10/2022
10 353503 WASLAN S 13/10/2022 15/10/2022
11 326054 ALIFAH BA 10/10/2022 12/10/2022
12 353761 KEYSA JUN19/10/2022 23/10/2022
13 172127 SUPRIADI 18/10/2022 19/10/2022
14 205015 RUBIAH 26/10/2022 28/10/2022
15 354139 RASYIDAH 24/10/2022 25/10/2022
16 341928 ALIKA NAU20/10/2022 22/10/2022
17 195513 AMARNABY11/10/2022 13/10/2022
18 284736 CONRAD R15/10/2022 18/10/2022
19 353102 MARIHOT 8/10/2022 12/10/2022
20 305355 SITI PATI 22/10/2022 22/10/2022
21 353887 ELY DELVIA20/10/2022 22/10/2022
22 182382 SEPTIAN A 19/10/2022 22/10/2022
23 354047 NAUFAL ZA23/10/2022 27/10/2022
24 145324 ANDREANSA 4/10/2022 8/10/2022
25 353949 DEVI MULI20/10/2022 23/10/2022
26 249056 TITIN SUM22/10/2022 26/10/2022
27 352569 TARIMAN 6/10/2022 9/10/2022
28 353607 HERNAWAT16/10/2022 16/10/2022
29 305084 AMALUDIN26/10/2022 27/10/2022
30 354049 MAWAR 22/10/2022 26/10/2022
31 353130 ABDULLAH9/10/2022 11/10/2022
32 352787 MUHAMMAD 19/10/2022 22/10/2022
33 326455 USMAN NA27/10/2022 30/10/2022
34 335162 DANI PARA6/10/2022 7/10/2022
35 353720 ZAINAL AB 17/10/2022 20/10/2022
36 278346 RAJILIN H 22/10/2022 26/10/2022
37 353599 YUPAWET 16/10/2022 16/10/2022
38 324046 NURLELA S5/10/2022 8/10/2022
39 353019 JOEL RUM 13/10/2022 14/10/2022
40 325949 RIDWAN R 9/10/2022 12/10/2022
41 196975 IMRAN RI 7/10/2022 14/10/2022
42 352917 RISKI SYA 5/10/2022 7/10/2022
43 353403 AL FITRAH 13/10/2022 14/10/2022
44 354133 BALQIS UL 24/10/2022 27/10/2022
45 354034 SHOFWATU24/10/2022 27/10/2022
46 309808 SURIANI 20/10/2022 22/10/2022
47 333979 NURMALA 7/10/2022 8/10/2022
48 274180 DONGMAUL 20/10/2022 22/10/2022
49 353288 IMAN SYA 10/10/2022 17/10/2022
50 299288 NURSIAH L25/10/2022 26/10/2022
51 260174 MESNI 11/10/2022 13/10/2022
52 261094 NEYSA VIO7/10/2022 8/10/2022
53 354131 ABDUL MUL 24/10/2022 27/10/2022
54 352712 CHESILA E 1/10/2022 4/10/2022
55 352662 NAYLA LAU30/9/2022 4/10/2022
56 331069 YUSPITA D 22/10/2022 26/10/2022
57 226984 PARIDAH N15/10/2022 16/10/2022
58 115525 HAPOSAN 10/10/2022 16/10/2022
 59 282170 FITRIYANI 29/9/2022 3/10/2022
60 352500 SALMAN KH 27/9/2022 4/10/2022
61 352695 AISYAH PUT1/10/2022 5/10/2022
62 264146 BOY ADITY20/10/2022 23/10/2022
63 291791 SUSILAWAT17/10/2022 19/10/2022
64 341504 HASBI NAI 29/09/2022 3/10/2022
65 307829 AMRAN 29/9/2022 1/10/2022
66 352728 ADITYA H 1/10/2022 3/10/2022
67 353863 BAMBANG19/10/2022 21/10/2022
68 341170 AMIN HAR3/10/2022 5/10/2022
69 142567 SOLIHIN 4/10/2022 7/10/2022
70 301581 ELSUANDI 24/10/2022 28/10/2022
71 334174 ROSMIDA 16/10/2022 18/10/2022
72 354225 SAMSUDIN25/10/2022 31/10/2022
73 353578 ABDUL HAR14/10/2022 17/10/2022
74 353598 MASLAINI 15/10/2022 18/10/2022
75 160270 ALI IMRAN17/10/2022 19/10/2022
76 353014 SUPARNO 6/10/2022 14/10/2022
77 353002 DELIANA R6/10/2022 7/10/2022
78 130912 LISTRA SR 9/10/2022 10/10/2022
79 352651 SALBIAH 30/09/2022 3/10/2022
80 331457 KEYLA ARI 13/10/2022 14/10/2022
81 325523 RIADI 11/10/2022 14/10/2022
82 274889 RIKO ANDR10/10/2022 11/10/20222
83 354052 KHAIRUL 23/10/2022 26/10/2022
84 341180 ERWIN 11/10/2022 13/10/2022
85 297326 DAHLIA 23/10/2022 25/10/2022
86 149489 HALIDAH 24/10/2022 26/10/2022
87 174605 TINI 22/10/2022 25/10/2022
88 242585 ARTA BR S 14/10/2022 17/10/2022
89 150494 SITI FATIM27/10/2022 31/10/2022
90 354167 SHAFA KHA25/10/2022 28/10/2022
91 309152 KHUSNI IN 7/10/2022 8/10/2022
92 353853 SAHAT MAR 27/10/2022 29/10/2022
93 354278 AZKAERZAR26/10/2022 28/10/2022
94 353361 MERCIA SH12/10/2022 14/10/2022
95 354419 SANI HUMA28/10/2022 31/10/2022
96 334926 WARDIZAN19/10/2022 23/10/2022
97 271875 ILHAM SA 10/10/2022 11/10/2022
98 280733 IRPAN ARI 8/10/2022 12/10/2022
99 340129 SARHINI S 14/10/2022 17/10/2022
100 342454 ABDUL KOD4/10/2022 7/10/2022
 FORMULI

UMU

Identitas Pasien ( Lembar Masuk dan Keluar )

General Concent
NAMA DOKTER DPJP

dr. Hj. Ida Maya R Pane, M.Ked(Pd). Sp.PD X ✓

dr. M Fadhly Sigalingging, M.Ked(PD), Sp.PD ✓ ✓
dr. Ismart, Sp.A ✓ ✓
dr. Windi, Sp.OT ✓ ✓
dr. Fransisco Pakpahan, M.Ked(Paru), Sp.P ✓ ✓
dr. Ismart, Sp.A ✓ ✓
dr. Syafril, Sp.B ✓ ✓
dr. Syafril, Sp.B ✓ ✓
dr. Windi, Sp.OT x ✓
dr. Reza,Sp.B ✓ ✓
dr. Novriyanti, Sp.PD X ✓
dr. Budi, Sp.B X ✓
dr. Novriyanti, Sp.PD X ✓
dr. T. Mira, Sp.PD ✓ ✓
dr. Dedy Shauqi, Sp.PD ✓ ✓
dr. Ismart, Sp.A ✓ ✓
dr.Budi, Sp.B ✓ ✓
dr. T. Mira, Sp.PD X ✓
dr. M Fadhly Sigalingging, M.Ked(PD), Sp.PD ✓ ✓
dr. Hj Ida Maya Br Pane, Sp.PD ✓ ✓
dr. Reza,Sp.B/dr. Kartika, Sp.JP ✓ ✓
dr. Windi, Sp.OT X ✓
dr. Irania , Sp.A X ✓
dr. Adi Subrata, Sp.A ✓ ✓
dr. Dedy Shauqi, Sp.PD ✓ ✓
dr. Hj Ida Maya Br Pane, Sp.PD ✓ ✓
dr.Syafril, Sp.B/ dr. Fransisco, Sp.P ✓ ✓
dr. Arif, Sp.S X ✓
dr. Dedy Shauqi, Sp.PD ✓ ✓
dr. Arif, Sp.S/dr. Rasyidin, Sp.KFR X ✓
dr. Fransisco Pakpahan, M.Ked(Paru), Sp.P X ✓
dr. Guntur Ginting, Sp.PD X ✓
dr. Dedy Shauqi, Sp.PD/ Dr. Faridah H Margolang, Sp.JP ✓ ✓
dr. Syafril, Sp.B ✓ ✓
dr. Fransisco Pakpahan, M.Ked(Paru), Sp.P ✓ ✓
dr. Hj Ida Maya Br Pane, Sp.PD ✓ ✓
dr. T. Mira, Sp.PD ✓ ✓
dr. Windi, Sp.OT ✓ ✓
dr. Fransisco Pakpahan, M.Ked(Paru), Sp.P/ dr. Putra, Sp.B ✓ ✓
dr. AYUHATI S, M.Ked(PD)Sp.PD X ✓
dr. M Fadhly Sigalingging, M.Ked(PD), Sp.PD/ dr. Rasyidin, Sp.KFR X ✓
dr. ARIF, Sp.S ✓ ✓
dr.Rachman M Putra, Sp.B ✓ ✓
dr. Irania , Sp.A ✓ ✓
dr. Irania , Sp.A ✓ ✓
dr. Guntur Ginting, Sp.PD/dr. Rachmad M Putra, Sp.B ✓ ✓
dr. Novriyanti, Sp.PD ✓ ✓
dr. Reza, Sp.B/ dr. Windi, Sp.OT ✓ ✓
dr. Irania , Sp.A/ dr. Said, Sp.An X ✓
dr. Dedy Shauqi FS, M.Ked(PD), Sp.PD ✓ ✓
dr. Dedy Shauqi FS, M.Ked(PD), Sp.PD ✓ ✓
dr. Adi Subrata, Sp.A x ✓
dr. Guntur Ginting, Sp.PD ✓ ✓
dr. Hj Ida Maya Br Pane, Sp.PD ✓ ✓
dr. Adi Subrata, Sp.A ✓ ✓
dr. Faridah Margolang, Sp.JP/ dr. Humberto, Sp.THT ✓ ✓
dr. T. Mira, Sp.PD ✓ ✓
dr. Fransisco S Pakpahan, M.Ked(Paru), Sp.P/ dr. M. Rasyidin, Sp.KFR X ✓
dr. SRI DAMAYANA, Sp.OG/ dr. Said, Sp.An ✓ ✓
dr. Adi Subrata, Sp.A X ✓
dr. Irania T Lubis, Sp.A X ✓
dr. Ismart, Sp.A ✓ ✓
dr. Guntur Ginting, Sp.PD ✓ ✓
dr. Adi Subrata, Sp.A ✓ ✓
dr. Novriyanti, Sp.PD ✓ ✓
dr. Irania, Sp.A X ✓
dr. T. Mira, Sp.PD X X
dr. Syafril, Sp.B ✓ ✓
dr. Faridah Margolang, Sp.JP ✓ ✓
dr. Dedy Shauqi, M.Ked(PD0, Sp. PD) X ✓
dr. AYUHATI S, M.Ked(PD)Sp.PD X ✓
Dr. H. Eddy Janis, Sp.P(K), FISR, FCCP ✓ ✓
dr. M. Fadhly Sigalingging, M.Ked(PD), Sp.PD X ✓
dr. Artisya Fajriani, M.Ked(Neu), Sp.S X ✓
dr. Guntur Ginting, Sp.PD ✓ ✓
dr. Fransisco S Pakpahan, M.Ked(Paru), Sp.P/ dr. Artisya Fajriani,M.Ked(Neu),Sp.S X ✓
dr. Artisya Fajriani, M.Ked(Neu), Sp.S ✓ ✓
dr. Rachmad M Putra, Sp.B X ✓
dr.Fransisco S Pakpahan,M.Ked(Paru), Sp.P X ✓
dr. Adi Subrata, Sp.A ✓ ✓
dr. Guntur Ginting, Sp.A ✓ ✓
dr. Hj Ida Maya Br Pane, Sp.PD ✓ ✓
dr. AYUHATI S, M.Ked(PD)Sp.PD ✓ ✓
dr. Arif, Sp.S/ dr. Hj. Ida Maya, M.Ked(PD), Sp.PD ✓ ✓
dr. Guntur Ginting Sp. PD ✓ ✓
dr. Budi, Sp.B ✓ ✓
dr. Farida, Sp.JP/dr. Hj. Ida Maya, M.Ked (PD), Sp.PD ✓ ✓
dr. M. Fadhly Sigalingging, M.Ked(PD), Sp.PD ✓ ✓
dr. Kartika, Sp.JP X ✓
dr. H Ady Subrata, Sp.A ✓ ✓
dr. H Ady Subrata, Sp.A ✓ ✓
dr. T. Mira, Sp.PD ✓ ✓
dr. Ismart, Sp.A ✓ ✓
dr. H Ady Subrata, Sp.A ✓ ✓
dr. H Ady Subrata, Sp.A ✓ ✓
dr. Windi, Sp.OT ✓ ✓
dr. Budi, Sp.B X ✓
dr. Putra, Sp.B ✓ ✓
dr. M Fadhly Sigalingging,m. Ked(PD), Sp.PD ✓ ✓
dr. Fransisco Pakpahan, M.Ked(Paru), Sp.P/ dr. Artisya Fajriani, M.Ked(Neu), Sp.S ✓ ✓
30 1
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Asesmen Awal Medis Rawat Inap

X
X

x
x

X
X
X
X
X
X
X
X
X
X
X
Pemberian Informasi dan Edukasi Pasien/Keluarga Terintegrasi

UMUM

-
-

-
-
-
-
-
-
-

X
X
X
X

✓
✓
Surat Persetujuan Tindakan Kedokteran

-
-

-
-
-
-
-
-
-
-
-
-
-
-
-
Surat Penolakan Tindakan Kedokteran

✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Pengkajian Pasien Gawat Darurat

X
X
X
X
X
X
X
X

✓
✓
✓
✓
✓
Resume Medis Rawat Inap

X
X

x
X
X
X
X

✓
✓
✓
✓
✓
✓
✓
✓
Resume Keperawatan

✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Catatan Perkembangan Terintegrasi Di Ruangan
RSUD RANTAUPRAPAT
PERIODE OKTOBER 2022

-
-
-
-
-
-
-
-
-
-
-
-

X
✓
MEDIS

Formulir Konsultasi Rawat Inap

x
x

X
X
X
X

✓
✓
✓
✓
✓
✓
✓
✓
✓

Catatan Pemberian Obat Tepat Waktu

FORMULIR ANALISIS KUANTITATIF BERKAS REKAM MEDIS PASIEN RAWAT INA
X X - - X X X ✓ - ✓
✓ X X - ✓ X ✓ ✓ ✓ ✓
✓ X X - ✓ X ✓ ✓ ✓ ✓
X X - - ✓ ✓ ✓ ✓ - ✓
✓ X - - X X X ✓ - ✓
✓ X ✓ - ✓ ✓ ✓ ✓ ✓ ✓
✓ X ✓ - ✓ X ✓ ✓ - X
✓ X - - ✓ ✓ ✓ ✓ - X
X X X - ✓ ✓ ✓ ✓ - X
✓ X - - X X ✓ ✓ - X
✓ X - - ✓ X X ✓ - X
✓ X X - ✓ X X ✓ ✓ X
✓ X - - ✓ ✓ X ✓ - X
X X X - ✓ X ✓ ✓ - X
✓ X - - ✓ X X ✓ ✓ ✓
X X - - ✓ X X ✓ - X
X X - - ✓ X X ✓ - X
✓ X - - X X X ✓ ✓ X
X X - - X X X ✓ - X
X X - - ✓ X X ✓ - X
X X X - X X X X ✓ X
X X - - ✓ ✓ ✓ ✓ - X
X X - - ✓ X X ✓ ✓ X
✓ X X - ✓ ✓ X ✓ ✓ -
X X - - ✓ X ✓ ✓ ✓ ✓
X ✓ - - ✓ X X ✓ X X
X X - - ✓ X X ✓ - ✓
✓ X X - ✓ X ✓ ✓ - X
✓ X - - ✓ X ✓ ✓ - X
✓ X - - ✓ X X ✓ - X
X X X - - X ✓ ✓ ✓ ✓
X X X - ✓ X ✓ ✓ - ✓
X X X - X X ✓ ✓ ✓ ✓
x X X - ✓ x ✓ ✓ ✓ ✓
✓ X X - ✓ X X ✓ - X
X X X - ✓ X X ✓ - X
✓ X - - ✓ x ✓ ✓ - ✓
X X - - ✓ X X ✓ - ✓
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X X - - ✓ ✓ ✓ ✓ - X
X X X - X X X ✓ ✓ ✓
X X - - ✓ X ✓ ✓ - ✓
X X - - ✓ X ✓ ✓ ✓ ✓
X X X - - X X ✓ ✓ ✓
✓ X - - ✓ ✓ ✓ ✓ - X
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X X X - ✓ X X ✓ - X
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✓ X X - ✓ X ✓ ✓ - ✓
✓ X - - ✓ ✓ X ✓ - X
X X - - ✓ X X ✓ - ✓
✓ X - - ✓ X ✓ ✓ - X
X ✓ - - ✓ X ✓ ✓ - ✓
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X X - - ✓ ✓ ✓ ✓ ✓ ✓
X X - - ✓ X X ✓ - ✓
X X - - ✓ X X ✓ - X
X X X - X X X ✓ - X
X ✓ - - ✓ X X ✓ ✓ ✓
X X - - ✓ X ✓ ✓ - X
✓ X ✓ - ✓ X ✓ ✓ - X
X ✓ - - ✓ X X ✓ ✓ ✓
✓ X - - ✓ ✓ ✓ ✓ - X
X X - - ✓ X X ✓ - ✓
X X X - ✓ X ✓ ✓ - ✓
X X - - ✓ X ✓ ✓ - X
X X X - ✓ X ✓ ✓ ✓ ✓
X X - - ✓ X X ✓ - X
✓ X ✓ - ✓ X ✓ ✓ - X
X X - - ✓ X X ✓ ✓ X
X X X - ✓ X X ✓ ✓ ✓
X X - - ✓ X X ✓ - X
✓ X - - ✓ ✓ ✓ ✓ - X
X X - - ✓ X ✓ ✓ - X
X X - - ✓ X ✓ ✓ ✓ ✓
✓ X - - ✓ X ✓ ✓ - X
✓ X - - ✓ X ✓ ✓ - X
✓ X - - ✓ X ✓ ✓ - ✓
X X ✓ - ✓ X ✓ ✓ ✓ X
X X ✓ - ✓ X X ✓ - X
X X X - ✓ X X ✓ ✓ X
X X - - ✓ X ✓ ✓ - X
X ✓ X - ✓ X X ✓ - ✓
51 95 28 0 10 81 46 1 2 52
PASIEN RAWAT INAP

TENAGA KESEHATAN LAIN OPERASI

Persetujuan Tindakan Kedokteran

Persetujuan Tindakan Anastesi

Surat konsultasi / Rujuk

Rehalibitas Medik

Dan Lain - Lain

Perawat

Farmasi
Dokter

Bidan

Gizi

- ✓ ✓ - - - - - - -
- ✓ ✓ - - - - - - -
- ✓ ✓ - - - - - - -
- ✓ ✓ - - - - - X -
- ✓ ✓ - - ✓ - - - -
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- ✓ ✓ - - ✓ - - X ✓
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- ✓ ✓ - ✓ - - - - -
- ✓ ✓ - - - - - - -
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- ✓ ✓ - - - - - - -
- ✓ ✓ - ✓ ✓ - - - -
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- ✓ ✓ - ✓ ✓ - - - -
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- ✓ ✓ - - - - - - -
- ✓ ✓ - - - - - - -
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- ✓ ✓ - - ✓ - - - -
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0 0 0 0 0 0 0 0 13 2
 -
-

-
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✓
✓
✓
✓
✓
Checklist Keselamatan Pasien Operasi

Tanggal :

-
-

-
-
-
-
-
-
-
-

X
✓
✓
✓
✓
OPERASI
Laporan Operasi

-
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-
-
-
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-
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-
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✓
✓
Status Anestesia

-
-

-
-
-
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-
-
-
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✓
✓
Formulir Perawatan Pasca Bedah

X
X
X

✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Transfer Pasien

-
-

-
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Pulang Atas Permintaan Sendiri

-
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-
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Surat Keterangan Lahir

-
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-
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Surat Keterangan Kematian

-
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-
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Surat Permintaan Visum
LAIN - LAIN

✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓

Nama Pasien
- - - - ✓ - - - - ✓
✓ ✓ ✓ ✓ X - - - ✓
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✓ ✓ ✓ ✓ ✓ - - - - ✓
X ✓ - - X - - - - ✓
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✓ X ✓ ✓ ✓ - - - - ✓
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✓ ✓ - - X - - - - ✓
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✓ ✓ ✓ ✓ X - - - - ✓
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✓ X - - - - - - - ✓
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✓ ✓ - - ✓ - - - - ✓
✓ ✓ ✓ X ✓ - - - - ✓
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✓ ✓ - - ✓ - - - - ✓
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✓ ✓ - - X - - - - ✓
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✓ ✓ X ✓ ✓ - - - - ✓
✓ ✓ - - X - - - - ✓
✓ ✓ - - ✓ - - - - ✓
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2 3 1 1 52 0 0 1 0 1
 KELENGKAPAN SETELAH DIPERIKSA

TIDAK LENGKAP (TD)

DIKIRIM 2 x 24 JAM
(L)
Tanggal Lahir/Umur

TIDAK TERBACA
No. Rekam Medis

TERBACA
LENGKAP

✓ ✓ ✓ - ✓ - ✓
✓ ✓ ✓ - ✓ - ✓
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