YAKKUM

Yayasan Kristen Untuk Kesehatan Umum

panduan
PENGIsIAN FORMULIR
REKAM MEDIK

RS. MARDI WALUYO

Jl. Jend. Sudirman No. 156

Kota Metro 34111
Telp. (0725) 42512, 44980,
Fax. (0725) 43053
Email : rs_mardiwaluyo@yahoo.co.id
 DAFTAR ISI

Halaman Judul
Daftar Isi ..................................................................................................... ii
Sampul Dokumen Rekam Medis...................................................................... 1
Rekam Medis Rawat Jalan............................................................................... 2
Ringkasan Masuk Dan Keluar Rawat Inap....................................................... 4
Sebab Kematian............................................................................................... 7
Status Pasien.................................................................................................... 8
Instalasi Gawat Darurat.................................................................................... 9
Perjalanan Penyakit Perintah Dokumen Dan Pengobatan................................ 11
Hasil Pemeriksaan Photo Rontgen Diagnostik / USG...................................... 12
Hasil Pemeriksaan Elektro Kardiografi............................................................ 13
Kartu Laboratorium.......................................................................................... 14
Hasil Pemeriksaan Laboratorium..................................................................... 15
Kartu Obat ....................................................................................................... 16
Daftar Pemberian Obat Injeksi......................................................................... 17
Daftar Pemberian Obat Oral............................................................................. 18
Balans Cairan................................................................................................... 19
Surat-surat Koserpondensi (Surat Rujukan)..................................................... 20
Pengkajian Keperawatan Bedah Dan Dalam.................................................... 21
Pengkajian Keperawatan Anak......................................................................... 22
Pengkajian Keperawatan Bayi......................................................................... 23
Pengkajian Asuhan Kebidanan......................................................................... 24
Pengkajian Keperawatan Intensive................................................................... 25
Diagnosa Keperawatan ................................................................................... 26
Catatan Tindakan Dan Perkembangan.............................................................. 27
Catatan Perawatan Intensive............................................................................ 28
Asuhan Kebidanan Dengan SOAP................................................................... 29
Laporan Pengawasan.10 Kamar Bersalin......................................................... 30
Laporan Persalinan........................................................................................... 31
Observasi Kala IV Persalinan.......................................................................... 32
Identifikasi Bayi Baru Lahir............................................................................. 33
Resume Kebidanan.......................................................................................... 34
Resume Perawatan........................................................................................... 35

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Pemberian Informasi........................................................................................ 36
Format Serah Terima Pasien IGD ke Ruanngan............................................... 37
Serah Terima Pasien Pindah Ruangan.............................................................. 38
Persetujuan Tindakan Medis............................................................................ 39
Persetujuan Pasien Rawat Inap........................................................................ 40
Surat Pernyataan Kehendak Pulang Paksa....................................................... 41
Pernyataan Penolakan ..................................................................................... 42
Persetujuan Pasien Dirawat di ICU ................................................................. 43
Surat Pernyataan.............................................................................................. 44
Pengkajian Prabedah........................................................................................ 45
Laporan Operasi............................................................................................... 46
Laporan Anestesi.............................................................................................. 47
Pengkajian Intraoperative / Postoperative........................................................ 48
Perincian Obat dan Alat-alat Operasi............................................................... 49
Ringkasan Pasien Perawatan Pasien Pulang / Pulang....................................... 50
Permintaan Jasa Konsul................................................................................... 51
Blangko Tindakan Keperawatan...................................................................... 52
Catatan Konseling Pastoral.............................................................................. 53

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