FORMAT UMUM CLINICAL PATHWAYS

LOGO CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

1 SMF OBGYN 2 RSUD RAA SOEWONDO PATI 3
Partus macet, placenta Previa, Partus tak maju, Kelainan letak, Ruptura Uteri IM,
Panggul Sempit, Gawat Janin, Induksi gagal, Vakum Gagal, ( Nama Penyakit )
2012 5
Nama Pasien : 6
Umur : 7 Berat Badan : 8 Tinggi Badan : 9 Nomor Rekam Medis : 10
.................................... ............ .........kg ............cm ..........................
Diagnosis Awal :..............................11 Kode ICD 10 :066,4,044,1,066,912 Rencana rawat : ..........hari 13
R. Rawat Tgl/Jam masuk : Tgl/Jam keluar : Lama rawat : Kelas : Tarif/hr (Rp) : Biaya (Rp) :
.....14....... .....15....... .....16....... .....17.....hari .....18....... .....19....... .....20.......
Aktivitas Pelayanan
Hari Rawat 1 Hari Rawat 2 21 Hari Rawat 3 Hari Rawat 4 Hari Rawat 5
Hari Sakit:... Hari Sakit:... Hari Sakit:... Hari Sakit:... Hari Sakit:...
Diagnosis :
* Penyakit Utama 22
* Penyakit Penyerta 23
* Komplikasi 24
Administrasi RM lengkap 30,000
Akomodasi Sewa kamar Sewa kamar Sewa kamar 5x30000 150,000
Akomodasi lain Akomodasi lai Akomodasi lain Akomodasi lain
Assesmen Klinis :
* Pemeriksaan dokter 25 dr. Sp. OG dr. Sp. OG dr. Sp. OG 5x30000 150,000
* Konsultasi 26 dr. SpA dr. SpA 5x25000 125,000
Pemeriksaan Penunjang27
Laborat Darah rutin 40,000
Gol Darah 8,500
Radiologi
Tindakan : 28
Medis Sectio SecariaImunisasi HB1, 1700000+15000 1,715,000
Resusitasi Polio , BCG 40000+15000 55,000

Keperawatan Vital Sign Breast Care Breast Care Breast Care Breast Care Askep 250,000
Observasi ba Vulva Hygiene Vulva Hygiene Vulva Hygiene Vulva Hygiene Sederhana 24,000
Observasi Ib Memandikan Bayi Memandikan Bayi Memandikan BayMemandikan Bayi Kecil 180,000
Injeksi Merawat tali pusar Merawat tali pusar Merawat tali pusaMerawat tali pusar Sedang 50,000
Caterisasi Ganti Balut Ganti Balut
Personal Hygiene Buka Jahitan
Isap lendir bayi
Pasang Infus
Pasang DC
Scaren
Obat-obatan : 29
Obat-obatan : 29 492500 Amoxycilin 3x Amoxycilin 3x 500 mg Amoxycilin 3x 500 Amoxycilin 3x 5 Amoxycilin 3x 500 mg
25200 Inj. Gentamici Inj. Gentamicin 80 gr Tab. As Met 3x500 Tab. As Met 3x5 Tab. As Met 3x500 mg
61868 Inj. Alinamin Inj. Alinamin 2x1 amp
27500 Profenit sup 2x1
12252 Inf. NACL 2 kolf
13000 Inf RL 2 kolf
6710 Inj. Amphicilin 1 gr
5830 o2
Obat pulang Amoxycilin 500 mg = 6
Tab. As Met 3x500 mg 202,110

BHP Kassa 1/20 rol Kassa 1/20 rol Kassa 1/20 rol
Hepavix 25 Hepavix 25 Hepavix 25
Kapas 5 gr Kapas 5 gr Kapas 5 gr
Hanschon = 2 ps Alkohol 70 % 200 cc Alkohol 70 % 200 cc
Chlorin 10 cc Hanschon = 2 ps Hanschon = 2 ps
Silet Chlorin 10 cc Chlorin 10 cc
Hansaplast 1
Betadine 200 cc
Alkohol 70 % 200 cc
Kassa steril 1 pack
Hepavix 25 cc
Mess no : 23 = 1 bh
Alkes Dispo 5 cc = 2
Jarum Spinal
Transfusi set
Abocat no 18
Policateter no 16 155,164
Nutrisi : 29 Makanan bias Makanan biasa Makanan biasa
Mobilisasi : 30
Hasil (Outcome): 31
*
*
*
Pendidikan/Rencana 32
Pemulangan :
Varians : 33

Jumlah Biaya 3,134,774

Nama Perawat : 36 Diagnosis Akhir 34
.............................. * Utama
Nama Dokter : 37 * Penyerta
......................
Nama Pelaksana * Komplikasi
Verifikasi : 38
......................
.............................
.............................
.............................
.............................
.............................
Kode ICD 10 Jenis Tindakan 35 Kode ICD 9 - CM
............................. * kode INA DRG : 146,101
............................. *
............................. *
............................. *
............................. *
 FORMAT UMUM CLINICAL PATHWAYS

LOGO CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

1 SMF BEDAH UMUM RSUD RAA SOEWONDO PATI 3
BPH dg OPERASI 4
2
1 Tahun 2013 5
Nama Pasien : 6
Umur : 7 Berat Badan : 8 Tinggi Badan : 9 Nomor Rekam Medis : 10
.................................... ............ .........kg ............cm ..........................
Diagnosis Awal :.............................. 11 2 Kode ICD 10 : N40.12 Rencana rawat : 12 hari 13
R. Rawat Tgl/Jam masuk1: Tgl/Jam keluar : Lama rawat : Kelas : Tarif/hr (Rp) : Biaya (Rp) :
..... .......
14
..... .......15
..... ....... 16
..... .....hari
17
..... .......
18
..... .......
19
.....20.......
Aktivitas Pelayanan
Hari Rawat 6 Hari Rawat 7 2 Hari Rawat 8 Hari Rawat 9
Hari Sakit:... Hari Sakit:... 1 Hari Sakit:... Hari Sakit:...
Diagnosis :
* Penyakit Utama 22 ................... ............................. .......................... ...................
* Penyakit Penyerta 23
................... ............................. .......................... ...................
* Komplikasi 24
................... ............................. .......................... ...................
Administrasi RM Lengkap ............................. .......................... ...................
Akomodasi Sewa kamar Sewa kamar Sewa kamar Sewa kamar 4x 30000 120,000
Akmds lain-lai Akmds lain-lain Akmds lain-lain Akmds lain-lain
Assesmen Klinis :
* Pemeriksaan dokter 25 dr.Sp.B dr.Sp.B dr.Sp.B dr.Sp.B 4x30000 120,000
* Konsultasi 26
............................. dr.Sp.PD ........................
dr.Sp.An
dr.Sp.P
Pemeriksaan Penunjang27 ................... ............................. .......................... ........................ .......................... .......................... ........................
Laborat Darah rutin ............................. .......................... ........................ .......................... ..........................
Urine rutin
GDS
Ureum-Creatinine
SGOT-SGPT
Gol Darah
CT/BT
Radiologi Cistography
Photo Thorax
Tindakan : 28
................... ............................. .......................... ........................ .......................... ..........................
* Dokter Protatectomy
Anatesi
* Keperawatan Vitalsign Vitalsign Vitalsign Vitalsign Vitalsign
Askep Askep Askep Askep Askep
EKG Pengawasan infus Pengawasan infus Pengawasan infusPengawasan infus
Pasang Infus Injeksi Pengawasan O2 Injeksi
Injeksi Rawat drain
Lavemen Redressing
Personal Hygiene
Obat-obatan : 29 Inf.NaCl = 2kolf Inf.D5 = 2kolf
Inf.RL = 4kolf Inf RL 2 kolf
Inj.Cefotaxim 2x1gr Inj.Cefotaxim 2x1gr Inj.Cefotaxim 2x1gr
Inj.Gentamycin=2x80mg Inj.Gentamycin=2x Inj.Gentamycin=2x80mg
Inj.As.Tramexamat=2 amp
Inj.Ketoprofen 3x1 amp Inj.Ketoprofen 3x1 Inj.Ketoprofen 3x1 amp
Inj.Ranitidin 2x1amp
Transfusi 2 kolf
Irigasi NaCl 1000cc=24fl
Obat Pulang Tab.Cipro 2x500mg ( 3 hari )
Tab.Ketoprofen 2x100 ( 3 hari )
antasida 10 (3 hari )

ObatAnestesi Inj.As.Traneksamat 2amp

Inj.Catapres 1 amp
Inj.Deksametason 2 amp
Inj.Efedrin 2 amp
Infus Fimahes 1 btl
Infus NaCl 1 btl
Infus RL 2 btl
Kaltrofen Suppo 2 suppo
Inj.Ketrolac 1 amp
Inj. Marcain 1 amp
Oksigen 200ltr.
Inj.Petidin 1 amp
Inj.Sedacum 1 amp
Inj.Sulfas Atropin 2 amp
Inj. Furosemide 1 amp
Aquabidest 25cc = 1 vial
BHP Jelly 10cc Glyserin 5cc
Alkohol 5cc Alkohol 160cc
 Betadine 10cc Betadine 160cc
Kapas 1gr Kapas 10gr
Kassa 5lbr Kassa 1/4 rol
Hepavix 5cm Hepavix 25cm
Plester 10cm Plester 10cm
Anti Septik 30cc
Handschoon 7 psg
Plester 2 mtr
BHP Anestesi Infus set 1 Handschoon 1psg
DC 2 way No.18 = 1 Hansaplast 1 buah
Abocat no.18 = 1 Infus set 1
Spuit 5cc = 1 Transfusi set 2
Spuit 3cc = 2 DC 3 way No.22 = 1
Urine bag = 1
Abocat No.18
kateter tip 50cc = 1
Spuit 10cc = 1
Spongostan = 2
Benang Zide 2.0 =1
Plain 2.0 = 2mtr
Chromix 0 = 1mtr
Mes No.23=1
Hepavix 25cm x 10 = 1
ALKES IV Cateter = 1 pcs
jarum spinal 1 pcs
Spuit 3cc = 2bh
Spuit 5cc = 2 bh
Transfusi set 1 pcs
Nutrisi : 29
Nasi Nasi Nasi Nasi 25000x 4 100,000
Mobilisasi : 30
Hasil (Outcome): 31
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
Pendidikan/Rencana 32 ................... ............................. .......................... ........................ ..........................
Pemulangan :
Varians : 33
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................

Jumlah Biaya 5,871,617

Nama Perawat : Diagnosis Akhir
36 34
Kode ICD 10 Jenis Tindakan 35
Kode ICD 9 - CM
.............................. * Utama .............................
2 N40 21 * Kode INACBG'S : 121101
Nama Dokter : 37 * Penyerta 1
............................. ............................. *
...................... ............................. ............................. *
Nama Pelaksana * Komplikasi ............................. ............................. *
Verifikasi : 38 ............................. ............................. *
......................

halaman 2
 FORMAT UMUM CLINICAL PATHWAYS

LOGO CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

1 SMF SYARAF RSUD RAA SOEWONDO PATI 3
PARAPLEGIA4
Tahun 2013 5
Nama Pasien : 6
Umur : 7 Berat Badan : 8 Tinggi Badan : 9 Nomor Rekam Medis : 10
.................................... ............ .........kg ............cm ..........................
Diagnosis Awal :..............................11 Kode ICD 10 : .....................12 Rencana rawat : 17 hari 13
R. Rawat Tgl/Jam masuk : Tgl/Jam keluar : Lama rawat : Kelas : Tarif/hr (Rp) : Biaya (Rp) :
.....14....... .....15....... .....16....... 17 HARI .....18....... .....19....... .....20.......
Aktivitas Pelayanan
Hari Rawat 7 Hari Rawat 8 21 Hari Rawat 9 Hari Rawat 10 Hari Rawat 11 Hari Rawat 12
Hari Sakit:... Hari Sakit:... Hari Sakit:... Hari Sakit:... Hari Sakit:... Hari Sakit:...
Diagnosis :
* Penyakit Utama 22 ................... ............................. .......................... ........................ .......................... ...................
* Penyakit Penyerta 23
................... ............................. .......................... ........................ .......................... ...................
* Komplikasi 24
................... ............................. .......................... ........................ .......................... ...................
Administrasi RM Lengkap ............................. .......................... ........................ .......................... ...................
Akomodasi Sewa kamar Sewa kamar Sewa kamar Sewa kamar Sewa kamar Sewa kamar 180,000
Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain
Assesmen Klinis :
* Pemeriksaan dokter 25 dr.Sp.S dr.Sp.S dr.Sp.S dr.Sp.S dr.Sp.S dr.Sp.S 180,000
* Konsultasi 26 dr.Sp.RM
Pemeriksaan Penunjang27
Laborat Darah rutin
GDS
Ureum - Creatinine
Urine
Tindakan : 28
* Dokter -
* Keperawatan Vitalsign Vitalsign Vitalsign Vitalsign Vitalsign
Observasi Pasien Observasi Pasien Observasi Pasien Observasi Pasien Observasi Pasien
Pasang Infus Pasang Infus
Pengawasan Infus Pengawasan Infus Pengawasan Infus Pengawasan Infus Pengawasan Infus
Injeksi Injeksi Injeksi Injeksi Injeksi
Pasang DC Vulva Hygiene Vulva Hygiene Vulva Hygiene Vulva Hygiene
Skin test
Redressing
Obat-obatan : 29 Infus RL=3kolf Infus RL=3kolf Infus RL=3kolf Infus RL=3kolf Infus RL=3kolf
Inj.Ceftriason 2x1 amp Inj.Ceftriason 2x1 amp Inj.Ceftriason 2x1 am Inj.Ceftriason 2x1 amp Inj.Ceftriason 2x1 amp
Inj.Dexamethason 3x1 amp Inj.Dexamethason 3x1 am Inj.Dexamethason 3x1 a Inj.Dexamethason 3x1 amp Inj.Dexamethason 3x1 amp
Inj. Cimetidine 2x1 amp Inj. Cimetidine 2x1 amp Inj. Cimetidine 2x1 amp Inj. Cimetidine 2x1 amp Inj. Cimetidine 2x1 amp
Asam mefenamat 3x1 tab Asmet 3x1 tab Asmet 3x1 tab Asmet 3x1 tab Asmet 3x1 tab
Obat pulang Tab. B Compleks = 10
Tab.Amoxicilin 500mg = 10
Asmet 3*500
BHP Hepavix 60cm
Plester kecil 3 rol
Betadine 30cc
Kassa steril 50 lembar
Alkohol 70%=50cc
Kapas 20gr
ALKES Ploli cateter = 2
Infus set = 6
Abocat = 6
Urine bag
Spuit 10cc = 22
Spuit 5cc = 20
Spuit 3cc = 61
Nutrisi : 29 Nasi Nasi Nasi Nasi Nasi Nasi 150,000
Mobilisasi : 30
Hasil (Outcome): 31
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
Pendidikan/Rencana 32 ................... ............................. .......................... ........................ ..........................
Pemulangan :
Varians : 33
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................

Jumlah Biaya 510,000

Nama Perawat : 36 Diagnosis Akhir 34 Kode ICD 10 Jenis Tindakan 35 Kode ICD 9 - CM
.............................. * Utama ............................. G.82.2 * Kode INACBG'S : D-4-10-III
Nama Dokter : 37 * Penyerta ............................. ............................ *
...................... ............................. ............................ *
Nama Pelaksana * Komplikasi ............................. ............................ *
Verifikasi : 38 ............................. ............................ *
......................

Halaman 2
 FORMAT UMUM CLINICAL PATHWAYS

LOGO CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

1 SMF PARU RSUD RAA SOEWONDO PATI 3
TB PARU 4
Tahun 2012 5
Nama Pasien : 6
Umur : 7 Berat Badan : 8 Tinggi Badan : 9 Nomor Rekam Medis : 10
.................................... ............ .........kg ............cm ..........................
Diagnosis Awal :..............................11 Kode ICD 10 : .....................12 Rencana rawat : ..........hari 13
R. Rawat Tgl/Jam masuk : Tgl/Jam keluar : Lama rawat : Kelas : Tarif/hr (Rp) : Biaya (Rp) :
.....14....... .....15....... .....16....... .....17.....hari .....18....... .....19....... .....20.......
Aktivitas Pelayanan
Hari Rawat 1 Hari Rawat 2 21 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 22 ................... ............................. .......................... ........................ .......................... ...................
* Penyakit Penyerta 23
................... ............................. .......................... ........................ .......................... ...................
* Komplikasi 24
................... ............................. .......................... ........................ .......................... ...................
Administrasi RM Lengkap ............................. .......................... ........................ .......................... ................... 30,000
Akomodasi Sewa kamar Sewa kamar Sewa kamar Sewa kamar Sewa kamar 8x30000 240,000
Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain
Assesmen Klinis :
* Pemeriksaan dokter 25 dr.Sp.P dr.Sp.P dr.Sp.P dr.Sp.P dr.Sp.P 8x30000 240,000
* Konsultasi 26
................... ............................. .......................... ........................ .......................... .......................... -
Pemeriksaan Penunjang27 ................... ............................. .......................... ........................ .......................... .......................... ........................
Laborat Darah rutin 40,000
SGOT - SGPT 34,000
Ureum-Creatinine 10,000
GDS
Radiologi Foto thorax 55,000
Tindakan : 28 ................... ............................. .......................... ........................ .......................... .......................... ..........................
* Dokter
* Keperawatan Infus ............................. .......................... ........................ .......................... ..........................
Injeksi
Vitalsign Vitalsign Vitalsign Vitalsign Vitalsign Vitalsign
Observasi Pasien Observasi Pasien Observasi Pasien Observasi Pasien Observasi Pasien Observasi Pasien
Pengawasan Infus Pengawasan Infus Pengawasan Infus
pasang O2 pasang O2 Redressing
Pengawasan O2 Pengawasan O2
Skin Test
Pasang Regestin
Obat-obatan : 29 Infus RL 3kolf Infus RL 3kolf Rifampicin 1x300mg Rifampicin 1x300mg Rifampicin 1x300mg Rifampicin 1x300mg 171,241
Inj.Ampicilin 3x1gr Inj.Ampicilin 3x1gr INH 1x300mg INH 1x300mg INH 1x300mg INH 1x300mg
* Ambroxol 3x1tab Ambroxol 3x1tab PZA 1x500mg PZA 1x500mg PZA 1x500mg PZA 1x500mg
Parasetamol 3x1tab Parasetamol 3x1tab Etambutol 1x500mg Etambutol 1x500mg Etambutol 1x500mg Etambutol 1x500mg
OBH Syrup
O2 1 tabung
BHP Aquabides 25cc
Aquades 100cc
kapas 5gr
Betadine 5cc
Alkohol 10cc
Plester 1 rol kecil
Hepavix 10cm
ALKES Infus set 1
Abocat 1
Spuit 5cc 4 buah
Spuit 3cc 1 buah
Selang O2 1 buah
Nutrisi : 29 TKTP TKTP TKTP TKTP TKTP 8x25000 200,000
Mobilisasi : 30

Hasil (Outcome): 31
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
Pendidikan/Rencana 32 ................... ............................. .......................... ........................ ..........................
Pemulangan :
Varians : 33
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................

Jumlah Biaya 1,020,241

Nama Perawat : Diagnosis Akhir36
.............................. * Utama
Nama Dokter : 37 * Penyerta
......................
Nama Pelaksana * Komplikasi
Verifikasi : 38
......................
34
Kode ICD 10 Jenis Tindakan 35 Kode ICD 9 - CM
............................. A16.2 * Kode INA DRG : O44151
............................. ............................. *
............................. ............................. *
............................. ............................. *
............................. ............................. *

halaman 1
 FORMAT UMUM CLINICAL PATHWAYS

LOGO CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

1 SMF BEDAH RSUD RAA SOEWONDO PATI 3
Fracture femur 4
Tahun 20125
Nama Pasien : 6
Umur : 7 Berat Badan : 8 Tinggi Badan : 9 Nomor Rekam Medis : 10
.................................... ............ .........kg ............cm ..........................
Diagnosis Awal :.............................. 11 Kode ICD 10 : S72.9 12 Rencana rawat : .8 hari 13
R. Rawat Tgl/Jam masuk : Tgl/Jam keluar : Lama rawat : Kelas : Tarif/hr (Rp) : Biaya (Rp) :
..... .......
14
..... .......
15
..... ....... 16
..... .....hari
17
..... .......
18
..... .......
19
.....20.......
Aktivitas Pelayanan
Hari Rawat 1 Hari Rawat 2 21 Hari Rawat 3 Hari Rawat 4 Hari Rawat 5
Hari Sakit:... Hari Sakit:... Hari Sakit:... Hari Sakit:... Hari Sakit:...
Diagnosis :
* Penyakit Utama 22
................... ............................. .......................... ........................ .......................... ...................
* Penyakit Penyerta 23
................... ............................. .......................... ........................ .......................... ...................
* Komplikasi 24 ................... ............................. .......................... ........................ .......................... ...................
Administrasi RM Lengkap ............................. .......................... ........................ .......................... ................... 30,000
Akomodasi Sewa kamar Sewa kamar Sewa kamar Sewa kamar Sewa kamar 5x30000 150,000
Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain
Assesmen Klinis :
* Pemeriksaan dokter 25 dr.Sp.BO dr.Sp.BO dr.Sp.BO dr.Sp.BO dr.Sp.BO 5x30000 150,000
* Konsultasi 26
dr.Sp.An ............................. .......................... ........................ .......................... 25,000
dr.Sp.PD 25,000
Pemeriksaan Penunjang27 ................... ............................. .......................... ........................ .......................... .......................... ........................
Laborat Darah rutin ............................. .......................... ........................ .......................... .......................... 40,000
CT/BT 5,000
Gol Darah 8,500
GDS 10,000
Ureum 17,000
Creatinine 17,000
SGOT-SGPT 34,000
HBsAg 45,000
Radiologi Foto Femur AP/LAT 55,000
Foto Thorax
Photo Pelvis
Tindakan : 28

* Dokter Orif 2,000,000

Anesthesi 800,000
* Keperawatan Pengawasan Infus Pengawasan Infus Pengawasan Infus Pengawasan Infus Pengawasan Infus
Pasang Infus Pasang Infus Pasang Infus
Observasi pasien Observasi pasien Observasi pasien Observasi pasien Observasi pasien
Vitalsign Vitalsign Vitalsign Vitalsign Vitalsign
Injeksi Injeksi Injeksi Injeksi Injeksi
Ganti balut Ganti balut Ganti balut
Memasang DC Nicrotomy Nicrotomy Nicrotomy Nicrotomy
Perekaman ECG
Obat-obatan : 29
Obat di Ruangan Inj. Cefotaxim 2x1gr Inj. Cefotaxim 2x1gr Inj. Cefotaxim 2x1gr Inj. Cefotaxim 2x1gr Inj. Cefotaxim 2x1gr
Inj. Ketoprofen 3x1 Inj. Ketoprofen 3x1 Inj. Ketoprofen 3x1 Inj. Ketoprofen 3x1 am Inj. Ketoprofen 3x1 amp
Inj. Kalnex 2x1 am Inj. Kalnex 2x1 a Inj. Kalnex 2x1 amp Inj. Kalnex 2x1 amp
Inf.D5 = 2 kokf
Darah 2 kantong
Inf. NaCl 2 kolf Inf. NaCl 2 kolf Inf. NaCl 1 kolf
Madecasol p3
Obat di IBS Inj. Pehacain 10 amp Oxoferin 2
Obat Anesthesi Inf. NaCl 3 kolf
Inj. Diprivan 1amp
Inj. Fortanes 1 amp
Inj.Petidin 2 amp
Inj. Sulfas Atropin 1 amp
Sevoflurane 25 ml
Aerane 25 ml
Halothane 25 ml
O2 1 jam 180ltr
N2O 150 ltr
Inf.RL 2 btl
Inj.Ketorolac = 1 amp
Obat pulang 143,562
BHP Alkohol 70 % 200 cc 273,100
IBS Betadine 200cc
Saflon 25 cc
Micosal 25 cc
Perhidrol 50 cc
Chromic 1 2 m
Plain no 1 2 m
Zide 2/0 1 m
kassa 100 lbr
Plester 1/4 rol
handschoon 6 psg
Infus RL 4 kolf Infus RL 4 kolf Infus RL 4 kolf Infus RL 4 kolf Infus RL 4 kolf
Anesthesi handschoon1 pcs
Hansaplast 1 lbr
kapas 1 gr
 FORMAT UMUM CLINICAL PATHWAYS

LOGO CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

1 SMF MATA RSUD RAA SOEWONDO PATI 3
TRABEKULEKTOMI / OPETASI ANTI GLAUKOMA DENGAN LA ( Nama Penyakit )
Tahun 2013 5
Nama Pasien : 6
Umur : 7 Berat Badan : 8 Tinggi Badan : 9 Nomor Rekam Medis : 10
.................................... ............ .........kg ............cm ..........................
Diagnosis Awal :..............................11 Kode ICD 10 : J.33.9 Rencana rawat : ..........hari 13
R. Rawat Tgl/Jam masuk : Tgl/Jam keluar : Lama rawat : Kelas : Tarif/hr (Rp) :
.....14....... .....15....... .....16....... .....174 hari .....18....... .....19.......
Aktivitas Pelayanan
Hari Rawat 6 Hari Rawat 7 21
Hari Sakit:... Hari Sakit:...
Diagnosis :
* Penyakit Utama 22
................... ............................. .......................... ........................ ..........................
* Penyakit Penyerta 23
................... ............................. .......................... ........................ ..........................
* Komplikasi 24 ................... ............................. .......................... ........................ ..........................
Administrasi RM Lengkap ............................. .......................... ........................ ..........................
Akomodasi Sewa kamar Sewa kamar 2x30000
Akmds lain-lain Akmds lain-lain
Assesmen Klinis :
* Pemeriksaan dokter 25 dr.SpM dr.SpM 2x30000
* Konsultasi 26

Pemeriksaan Penunjang27
Laborat Darah Rutin
GDS
CT BT

Radiologi
Tindakan : 28

* Dokter ECG

* Keperawatan Pasang Infus

Pengawasan Infus Pengawasan Infus Pengawasan Infus
Vitalsign Vitalsign Vitalsign
Observasi Pasien Observasi Pasien Observasi Pasien
PENKES
Rekam ECG
Obat-obatan : 29 19500 Infus RL 2 kolf
* Obat Tab. Amoxicilin 3x500m Tab. Amoxicilin 3x500 Tab. Amoxicilin 3x500mg
16489 Inj. Penitidine = 1 amp
Inj.Fortanes = 1 amp
Xylocain Spray 1/50 btl
11077 Tab. As. Met 3x Tab. As. Met 3xTab. As. Met 3x1
* Obat pulang Tab. Amoxicilin 3x500mg
Tab. As. Met 3x1
BHP 47066 Kasa 1/4 rol
Alkohol 70% 10 cc
Plester 1/4 gul
Betadine 10cc

ALKES Infus set 1Abocat 1

Spuit 5cc 4
Spuit 3cc 2
CSSD
Nutrisi : 29
Nasi Nasi 2x30000
Mobilisasi : 30

Hasil (Outcome): 31
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
Pendidikan/Rencana 32 ................... ............................. .......................... ........................ ..........................
Pemulangan :
Varians : 33
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
Jumlah Biaya
Nama Perawat : 36 Diagnosis Akhir 34 Kode ICD 10 Jenis Tindakan 35 Kode ICD 9 - CM
.............................. * Utama ............................. J.35.0 * Kode INA DRG : O31.151
Nama Dokter : 37 * Penyerta ............................. ............................. *
...................... ............................. ............................. *
Nama Pelaksana * Komplikasi ............................. ............................. *
Verifikasi : 38 ............................. ............................. *
......................
T UMUM CLINICAL PATHWAYS

CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

SMF MATA RSUD RAA SOEWONDO PATI 3
KTOMI / OPETASI ANTI GLAUKOMA DENGAN LA ( Nama Penyakit )4
Tahun 2013 5
Nomor Rekam Medis : 10

Biaya (Rp) :
.....20.......

60,000

60,000

60,000

1,022,476

Kode INA DRG : O31.151

Halaman 2
 FORMAT UMUM CLINICAL PATHWAYS

LOGO CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

1 SMF MATA DAN THT RSUD RAA SOEWONDO PATI 3
Cataract, Glaukoma( Nama Penyakit )4
Tahun 2012 5
Nama Pasien : 6
Umur : 7 Berat Badan : 8 Tinggi Badan : 9 Nomor Rekam Medis : 10
.................................... ............ .........kg ............cm ..........................
Diagnosis Awal :..............................11 Kode ICD 10 : Rencana rawat : ..........hari 13
R. Rawat Tgl/Jam masuk : Tgl/Jam keluar : Lama rawat : Kelas : Tarif/hr (Rp) :
.....14....... .....15....... .....16....... .....17.....hari .....18....... .....19.......
Aktivitas Pelayanan
Hari Rawat 1 Hari Rawat 2 21 Hari Rawat 3
Hari Sakit:... Hari Sakit:... Hari Sakit:...
Diagnosis :
* Penyakit Utama 22
................... ............................. .......................... ........................ ..........................
* Penyakit Penyerta 23
................... ............................. .......................... ........................ ..........................
* Komplikasi 24 ................... ............................. .......................... ........................ ..........................
Administrasi RM Lengkap ............................. .......................... ........................ ..........................
Akomodasi Sewa kamar Sewa kamar Sewa kamar Sewa kamar Sewa kamar 5x30000
Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain
Assesmen Klinis :
* Pemeriksaan dokter 25 dr.SpM dr.SpM dr.SpM dr.SpM dr.SpM
* Konsultasi 26
dr.Sp.PD
dr.Sp.An
Pemeriksaan Penunjang27
Laborat GDS
Darah Rutin
Ureum
Creatinin
CT BT
SGPT
SGOT
Radiologi Foto Thorax
Tindakan : 28

* Dokter
di IBS ECG EKEK IOL, Trabelculectomi
Anesthesi ECG

* Keperawatan Vitalsign
Rekam ECG Vitalsign Vitalsign Vitalsign Vitalsign Askep
Pasang Infus Observasi Observasi Observasi Sederhana
Secrent Injeksi Injeksi Injeksi Kecil
Pengawasan Infus Pengawasan Infus Pengawasan Infus Pengawasan Infus EKG
Redresing Rawat Luka Rawat Luka Rawat Luka
Ambulansi

Obat-obatan : 29
* Obat
Obat IBS BSS 250 ml
Provis 0,5
Benang Nylon 10-01/2
Injeksi Markain 1/5 amp
Inj. Xylocain 1/5 amp
Trypan blue 1/5
Silve Knife 1/5
Lensa taman 1
Bovie Aaron 1/5
* Obat Anestesi Diprivan 1 amp 132293
Inj. Sedacum 2 amp 2337
Pethidine 1 amp 164295
Dexamethason 2 am 1603
SA 1 AMP 3176
Ephedrin 1 amp 15125
Aminophylin 1 amp 68885
Nokoba 1/10 amp 8250
Dextrose 5 % 100 cc 10209
Infus RL 1 kolf 6500
O2 150 L
*Obat Ruangan Diamox tab 3x1 Inj. Gentamycin 1 amp Diamox tab 3x1 Diamox tab 3x1 Diamox tab 3x1
Infus RL 3 kolf Inj. Dexamethason 1 a Sefadroxil cap 500 mg Sefadroxil cap 500 Sefadroxil cap 500 mg 3x1
C. Mydriatil TM 1/3 btl As Met tab 500 mgAs Met tab 500 As Met tab 500 mg 3x1
Methil prednisolon Methil prednisol Methil prednisolon 8 mg tab 3x1
C. Xytrol SM 1 tab
* Obat pulang Diamox tab 3x1= 9
Sefadroxil cap 500 mg 3x1= 8
As Met tab 500 mg 3x1 = 7
Methil prednisolon 8 mg tab 3x1= 7
AT UMUM CLINICAL PATHWAYS

CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

SMF MATA DAN THT RSUD RAA SOEWONDO PATI 3
Cataract, Glaukoma( Nama Penyakit )4
Tahun 2012 5
Nomor Rekam Medis : 10

Biaya (Rp) :
.....20.......

31,000
150,000

150,000
25,000
25,000

10,000
40,000
17,000
17,000
5000
17000
17000
-
55,000

1,200,000
25,000
480,000

100,000
24,000
210,000
25,000

223,902

81,592
 FORMAT UMUM CLINICAL PATHWAYS

LOGO CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

1 SMF P. DALAM RSUD RAA SOEWONDO PATI 3
DHF GRADE 1,4
Tahun 2013 5
Nama Pasien : 6
Umur : 7 Berat Badan : 8 Tinggi Badan : 9 Nomor Rekam Medis : 10
.................................... ............ .........kg ............cm ..........................
Diagnosis Awal :..............................11 Kode ICD 10 : A.91 Rencana rawat : 9 hari 13
R. Rawat Tgl/Jam masuk : Tgl/Jam keluar : Lama rawat : Kelas : Tarif/hr (Rp) : Biaya (Rp) :
..... .......
14
..... .......
15
..... ....... 16
..... .....hari
17
..... .......
18
..... .......
19
.....20.......
Aktivitas Pelayanan
Hari Rawat 1 Hari Rawat 2 21 Hari Rawat 3 Hari Rawat 4 Hari Rawat 5
Hari Sakit:... Hari Sakit:... Hari Sakit:... Hari Sakit:...
Diagnosis :
* Penyakit Utama 22 ................... ............................. .......................... ........................ .......................... ...................
* Penyakit Penyerta 23
................... ............................. .......................... ........................ .......................... ...................
* Komplikasi 24 ................... ............................. .......................... ........................ .......................... ...................
Administrasi ................... ............................. .......................... ........................ .......................... ................... -
Akomodasi Sewa kamar Sewa kamar Sewa kamar Sewa kamar 10,000 40,000
Assesmen Klinis : Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain 7,500 30,000
* Pemeriksaan dokter 25 dr.Sp.PD dr.Sp.PD dr.Sp.PD dr.Sp.PD 5,000 20,000
* Konsultasi 26
Pemeriksaan Penunjang27
Laborat Darah rutin Darah rutin
IgG, IgM dengue
Radiologi
Tindakan : 28
* Dokter Pengawasan transfusi
* Keperawatan ASKEP Askep 180,000
Injeksi Injeksi Sederhana 40,000
Pasang Infus Redressing Kecil 360,000
Balance cairan Balance cairan Balance cairan

Balance cairan

Obat-obatan : 29 Infus RL 3 kolf Infus RL 3 kolf

Inj ranitidin 2 x 1amp
Tab.Paracetamol 3 Tab.Paracetamol 3x50 Tab.Paracetamol 3x500m Tab.Paracetamol 3x500mg
Vit.B Compleks 3x1 Vit.B Compleks 3x1 Vit.B Compleks 3x1 Vit.B Compleks 3x1
Vit C 3x1 Vit C 3x1 Vit C 3x1 Vit C 3x1

Obat Pulang
Vit.B Compleks = 10
Vit.C = 10 151,846
BHP
ALKES
Nutrisi : 29
Diet Lunak Diet Lunak Diet Lunak Diet Lunak 30,000
Mobilisasi : 30

Hasil (Outcome): 31
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
Pendidikan/Rencana 32 ................... ............................. .......................... ........................ ..........................
Pemulangan :
Varians : 33
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
Jumlah Biaya 851,846
Nama Perawat : 36 Diagnosis Akhir 34 Kode ICD 10 Jenis Tindakan 35 Kode ICD 9 - CM
.............................. * Utama ......................... A.91 * Kode INA DRG : 184122
Nama Dokter : 37 * Penyerta ............................. ............................. *
...................... ............................. ............................. *
Nama Pelaksana * Komplikasi ............................. ............................. *
Verifikasi : 38 ............................. ............................. *
......................

halaman 1
 FORMAT UMUM CLINICAL PATHWAYS

LOGO CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

1 SMF KULIT RSUD RAA SOEWONDO PATI 3
LEPROCY, DERMATITIS, VARICELLA, HERPES 4
Tahun 2013 5
Nama Pasien : 6
Umur : 7 Berat Badan : 8 Tinggi Badan : 9 Nomor Rekam Medis : 10
.................................... ............ .........kg ............cm ..........................
Diagnosis Awal :..............................11 Kode ICD 10 : .....................12 Rencana rawat : ..........hari 13
R. Rawat Tgl/Jam masuk : Tgl/Jam keluar : Lama rawat : Kelas : Tarif/hr (Rp) : Biaya (Rp) :
..... .......
14
..... .......
15
..... ....... 16
..... 6 hari
17
..... .......
18
..... .......
19
.....20.......
Aktivitas Pelayanan
Hari Rawat 1 Hari Rawat 2 21 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 22 ................... ............................. .......................... ........................ ..........................
* Penyakit Penyerta 23
................... ............................. .......................... ........................ ..........................
* Komplikasi 24
................... ............................. .......................... ........................ ..........................
Administrasi RM Lengkap ............................. .......................... ........................ .......................... 31,000
Akomodasi Sewa kamar Sewa kamar Sewa kamar Sewa kamar Sewa kamar Sewa kamar 180,000
Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain
Assesmen Klinis :
* Pemeriksaan dokter 25 dr.Sp.KK dr.Sp.KK dr.Sp.KK dr.Sp.KK dr.Sp.KK dr.Sp.KK 180,000
* Konsultasi 26
dr.Sp.PD 30,000

Pemeriksaan Penunjang27
Laborat Darah rutin GDS GDS GDS GDS 45,000
BTA 50,000
GDS
Radiologi -
Tindakan : 28
* Dokter -
* Keperawatan Kompres, Ganti BaluKompres, Ganti Balut Kompres, Ganti Balut Kompres, Ganti Balut Kompres, Ganti Balut 140,000
Infus, Injeksi Infus, Injeksi Infus, Injeksi Infus, Injeksi Infus, Injeksi Infus, Injeksi 32,000
Redressing Redressing Redressing 420,000
Observasi tanda vitaObservasi tanda vital Observasi tanda vital Observasi tanda vital Observasi tanda vital Observasi tanda vital
Oral Hygiene Oral Hygiene Oral Hygiene Oral Hygiene Oral Hygiene Oral Hygiene
Pengawasan Infus Pengawasan Infus Pengawasan Infus Pengawasan Infus Pengawasan Infus Pengawasan Infus
Memandikan Memandikan Memandikan Memandikan Memandikan
Observasi Pasien Observasi Pasien Observasi Pasien Observasi Pasien Observasi Pasien Observasi Pasien
Obat-obatan : 29 97500 Inf D5 & RL 3kolf Inf D5 & RL 3kolf Inf D5 & RL 3kolf Inf D5 & RL 3kolf Inf D5 & RL 3kolf
148500 Inj.Amoxicilin 3x1gr Inj.Amoxicilin 3x1gr Inj.Amoxicilin 3x1gr Inj.Amoxicilin 3x1gr Inj.Amoxicilin 3x1gr Inj.Amoxicilin 3x1gr
1728 Tab.Prednison 3x2 Tab.Prednison 3x2 Tab.Prednison 3x2 Tab.Prednison 3x2 Tab.Prednison 3x2 Tab.Prednison 3x2
13266 Tab.Interhistin 3x1 Tab.Interhistin 3x1 Tab.Interhistin 3x1 Tab.Interhistin 3x1 Tab.Interhistin 3x1 Tab.Interhistin 3x1
57750 Salep Betason N= 1 Salep Betason N= 1 Salep Betason N= 1 Salep Betason N= 1 Salep Betason N= 1 Salep Betason N= 1
6546 Ofloxacin 400mg x Ofloxacin 400mg x 1 Ofloxacin 400mg x 1 Ofloxacin 400mg x 1 Ofloxacin 400mg x 1 Ofloxacin 400mg x 1
4849 Acyclovir 5x800mg Acyclovir 5x800mg Acyclovir 5x800mg Acyclovir 5x800mg Acyclovir 5x800mg Acyclovir 5x800mg
3960 Asmef 3x500mg Asmef 3x500mg Asmef 3x500mg Asmef 3x500mg Asmef 3x500mg Asmef 3x500mg 411,359
BHP Rivanol 500cc Rivanol 500cc Rivanol 500cc Rivanol 500cc Rivanol 500cc Rivanol 500cc 759,189
Betadine 60cc Betadine 60cc Betadine 60cc Betadine 60cc Betadine 60cc Betadine 60cc
Kassa 1/4 rol Kassa 1/4 rol Kassa 1/4 rol Kassa 1/4 rol Kassa 1/4 rol Kassa 1/4 rol
Plester 1/2 rol Plester 1/2 rol Plester 1/2 rol Plester 1/2 rol Plester 1/2 rol Plester 1/2 rol
Perban 5cm=5 rol Perban 5cm=5 rol Perban 5cm=5 rol Perban 5cm=5 rol Perban 5cm=5 rol Perban 5cm=5 rol
Kapas 5gr Kapas 5gr Kapas 5gr Kapas 5gr Kapas 5gr Kapas 5gr
Alkohol 96%=5cc Alkohol 96%=5cc Alkohol 96%=5cc Alkohol 96%=5cc Alkohol 96%=5cc Alkohol 96%=5cc
handschoon = 4 handschoon = 4 handschoon = 4 handschoon = 4 handschoon = 4 handschoon = 4
ALKES Abocat = 1 Abocat = 1 Abocat = 1 115,509
Infus set = 1 Infus set = 1 Infus set = 1
Spuit 5cc = 4 Spuit 5cc = 4 Spuit 5cc = 4 Spuit 5cc = 4 Spuit 5cc = 4
Spuit 3cc = 1 Spuit 3cc = 1 Spuit 3cc = 1 Spuit 3cc = 1 Spuit 3cc = 1
Nutrisi : 29
TKTP TKTP TKTP TKTP TKTP 6X55.000 330,000
Mobilisasi : 30
Mobilisasi Mobilisasi Mobilisasi Mobilisasi Mobilisasi Mobilisasi
Hasil (Outcome): 31
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
* ................... ............................. .......................... ........................ ..........................
Pendidikan/Rencana 32 ................... ............................. .......................... ........................ ..........................
Pemulangan :
Varians : 33
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
................... ............................. .......................... ........................ ..........................
Jumlah Biaya 2,724,057
Nama Perawat : 36 Diagnosis Akhir 34 Kode ICD 10 Jenis Tindakan 35 Kode ICD 9 - CM
* Utama ............................. A30.4,A30.9,L30. * Kode INA DRG : O94101
.............................. B01.9, B02.9
Nama Dokter : 37 * Penyerta ............................. ............................ *
...................... ............................. ............................ *
Nama Pelaksana * Komplikasi ............................. ............................ *
Verifikasi : 38 ............................. ............................ *
......................

halaman 1
 FORMAT UMUM CLINICAL PATHWAYS

LOGO CLINICAL PATHWAYS DAN SISTEM DRGs CASEMIX

1 SMF ANAK RSUD RAA SOEWONDO PATI 3
NEONATAL INFEKSI dengan Berat Badan>= 25004
Tahun 2013 5
Nama Pasien : 6
Umur : 7 Berat Badan : 8 Tinggi Badan : 9 Nomor Rekam Medis : 10
.................................... ............ .........kg ..........................
Diagnosis Awal :..............................11 Kode ICD 10 : .....................12 Rencana rawat : ..........hari 13
R. Rawat Tgl/Jam masuk : Tgl/Jam keluar : Lama rawat : Kelas : Tarif/hr (Rp) : Biaya (Rp) :
.....14....... .....15....... .....16....... .....17.....hari .....18....... .....19....... .....20.......
Aktivitas Pelayanan
Hari Rawat 7 Hari Rawat 8 2 Hari Rawat 9 Hari Rawat 10 Hari Rawat 11 Hari Rawat 12
Hari Sakit:... Hari Sakit:... 1 Hari Sakit:... Hari Sakit:... Hari Sakit:... Hari Sakit:...
Diagnosis :
* Penyakit Utama 22 ................... ............................ .......................... ........................ .......................... ...................
* Penyakit Penyerta 23
................... ............................ .......................... ........................ .......................... ...................
* Komplikasi 24
................... ............................ .......................... ........................ .......................... ...................
Administrasi
Akomodasi Sewa kamar Sewa kamar Sewa kamar Sewa kamar Sewa kamar Sewa kamar 360,000
Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain Akmds lain-lain
Assesmen Klinis :
* Pemeriksaan dokter 25 dr.Sp.A dr.Sp.A dr.Sp.A dr.Sp.A dr.Sp.A dr.Sp.A 360,000
* Konsultasi 26
Pemeriksaan Penunjang27
Laborat

inj meropenem 2x100 mg inj meropenem 2x100 inj meropenem 2x100 inj meropenem 2x 10 inj meropenem 2x 10 inj meropenem 2x 100 mg

Radiologi
Tindakan : 28
* Dokter
* Keperawatan 140,000
450,000

*Fisioterapi
Obat-obatan : 29 Infus 41 = 4kolf 47,024

BHP Kassa steril 2

Kapas putih 25gr
Kapas lemak 100gr
Aquabidest 25cc 42,020
ALKES Abocat No.24 91,012
Nutrisi : 29 ASI ASI ASI ASI ASI ASI 7,500
Mobilisasi : 30

Hasil (Outcome): 31
* ................... ............................ .......................... ........................ ..........................
* ................... ............................ .......................... ........................ ..........................
* ................... ............................ .......................... ........................ ..........................
Pendidikan/Rencana 32 ................... ............................ .......................... ........................ ..........................
Pemulangan :
Varians : 33
................... ............................ .......................... ........................ ..........................
................... ............................ .......................... ........................ ..........................
................... ............................ .......................... ........................ ..........................

Jumlah Biaya 1,497,556

Nama Perawat : Diagnosis Akhir36 34
Kode ICD 10 Jenis Tindakan 35
Kode ICD 9 - p39.9
.............................. * Utama ............................ p39.9 * Kode INA CBGs : P-8-0-III
Nama Dokter : 37 * Penyerta ............................ ............................ *
...................... ............................ ............................ *
Nama Pelaksana * Komplikasi ............................ ............................ *
Verifikasi : 38 ............................ ............................ *
......................

halaman 2