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IV.

OBSTETRICS OUTPATIENT REPORT


Thursday, April 23rd, 2015 until Wednesday April 29th, 2015
Obstetric outpatient chief :
1. dr. Rodiani
2. dr. Hendra Sugama Saputra
TOTAL

: patients
: patients
: patients

DATE
US examination
April 23rd
April 24th
April 25th
April 26th
April 27th
April 28th
April 29th
TOTAL

MOW

Total procedure
Suture removal

1
3
3

0
Holiday

7
3

Implant
insertion
2
3
2

IUD insertion

0
1
0

8
5
1

5
3
2

TOTAL

DATE
1
3
3

VISITE
Lactation &
puerperal
4
1
0

7
3

1
0

Obstetric
April 23rd
April 24th
April 25th
April 26th
April 27th
April 28th
April 29th
TOTAL

Family
Obstetric
Planning
7
1
6
3
10
3
Holiday
9
7
7
3
1

PATIENT
Lactation &
puerperal
4
1
0
1
0

Family
Planning
7
6
10
9
7
1

1. dr. Rodiani
OBSTETRIC CASE
No
1

Initial
DIA

CAT

Age
24

24

Add
UA

Diagnosis
G2P1A0 37 weeks gestational
age not inlabor with prior CS
1x (o.i transverse lie) SLF
transverse lie

US

38 weeks gestational age SLF


cephalic presentation with
suspicion of IUGR
G2P1A0 9 weeks gestational
age with ureterolithiasis SLF
Intra uterine

UA

ICD Code
Z.34
N.21

Treatment/Plan
1x400g
Recontrolled
within 1 week
- Informed consent

Physician
FCH-ROD

Z.34
N.21

RZM-ROD

1x400g
Recontrolled
within 2 week
Informed consent

US

LACTATION AND PUERPURAL


No.
Initial
Age
Add

8 weeks gestational age SLF


intrauterine

Diagnosis

ICD Code

Treatment/Plan

Physician

1.

EVI

31

UA

P2A0 post LSCS due to


macrosemia day 13rd

082.1

Roborantia

BOY-SUG

NIG

23

UA

P2A0 post spontaneous


Delivery day 10th

082.1

Roborantia

BOY-SUG

FAMILY PLANNING
No.

Initial

Age

YUS

29

Status
(New/Old)/Date
March 30th 2015

LIS

31

March 31st 2015

MAR

33

March 31st 2015

NET

26

March 31st 2015

PAS

41

March 31st 2015

NO
1
2
3

ASSESMENT

dr. Rodiani
Report technique
Paper acknowledgment
Honesty
Mean

Diagnosis

Contraception

Physician

P2A0 post spontaneous bracht


delivery (day 2)
O75.82
P3A0 post spontaneous
delivery (outside) + post
Brandt Andrew maneuver due
to placental retention (day 2)
O75.82
P3A0 post spontaneous
delivery (outside) + post
manual plasentae due to
placental retention (day 2)
O75.82
P1A0 post spontaneous
delivery (day 2)
O75.82
P5A0 post spontaneous
delivery with severe
preeclamsia + partial HELLP
Syndrome (day 4)
O75.82
O14.13
O14.22

IUD
Z97.5

BOY-SUG

IUD
Z97.5

BOY-ROD

IUD
Z97.5

BOY-ROD

IUD
Z97.5

BOY-ROD

IUD
Z97.5

BOY-ROD

VALUE MAX

Notes

30
35
35
100

2 dr. Hendra Sugama


OBSTETRIC CASE
No. Initial Age Add
1
MIN
35
UA

US

MET

18

UA

US

Diagnosis
G2P1A0 25 weeks gestational
age SLF Intra uterine with
suspicion of right solid ovarian
neoplasm
22 weeks gestational age SLF
intra uterine + subserous
uterine myoma
G1P0A0 29 weeks gestational
Twin Life Fetus breech
presentation transvere lie

SUN

32

Z.34

UA

29 weeks Twin Life Fetus


breech presentation-transvere
lie

LACTATION AND PUERPERAL


No.
Initial
Age
Add
1

ICD Code
Z.34
Xxx

Diagnosis
P4A0 post LSCS due to
placentae previa totalis with
active bleeding + pomeroy
tubectomy day 10th

Treatment/Plan
1x400g
Recontrolled within 2
week

Physician
FCH-SUG

1x400g
Recontrolled within 2
week
Informed concern

EDP-ROD

ICD Code

Treatment/Plan

Physician

082.1

Roborantia

ROB-SUG

FAMILY PLANNING
No.

Initial

Age

TEN

23

Status
(New/Old)/Date
March 26th 2015

LIS

33

March 30th 2015

LIT

29

March 30th 2015

MAR

25

March 30th 2015

ROS

29

March 30th 2015

Physician

Diagnosis

Contraception

P2A1 post
spontaneous
delivery (day 2)
O75.82
P2A0 post
spontaneous
delivery (day 2)
O75.82
P2A0 post SSTP due
to uterine inversion
(day 2)
O75.82
P2A1 post
spontaneous
delivery (day 2)
O75.82
P3A0 post
spontaneous
delivery (day 2)
O75.82

IUD
Z97.5

ROB-ROD

IUD
Z97.5

BOY-SUG

IUD
Z97.5

BOY-SUG

Impant Insertion
Z30.49

BOY-SUG

Impant Insertion
Z30.49

BOY-SUG

NO
1
2
3

ASSESMENT
dr. Hendra Sugama
Report technique
Paper acknowledgment
Honesty
Mean

VALUE MAX

Notes

30
35
35
100

Total
OBSTETRIC CASE
No
1

Initial
TUT

ALI

Age
28

29

Add
UA

Diagnosis
G1P0A0 38 weeks gestational
age not inlabor with condiloma
accuminata SLF cephalic
presentation

US

36 weeks gestational age SLF


cephalic presentation
G7P5A1 35 weeks gestational
age not inlabor SLF breech
presentation

UA

US
3

IND

25

UA
US

SUL

28

UA

36 weeks gestational age SLF


cephalic presentation
G2P1A0 18 weeks gestational
age SLF intrauterine
17 weeks gestational age SLF
intrauterine
G2P1A0 12 weeks gestational
age SLF intrauterine

ICD Code
Z.34
078.11

Z.34
O80.1

Treatment/Plan
Sulfas ferrous
1x200mg
- Kalk 1x1 tablet
- Recontrolled
within 1 week

Physician
FCH-SUG

Sulfas ferrous
1x200mg
Kalk 1x1 tablet
Recontrolled
within 2 week

CGH-ROD

Sulfas ferrous
1x200mg
Kalk 1x1 tablet
Recontrolled
within 1 month
Sulfas ferrous
1x200mg
Folic acid
1x400g
Neurodex tab 1x1
Kalk 1x1 tablet
Recontrolled
within 2 month
Sulfas ferrous
1x200mg
Kalk 1x1 tablet
Recontrolled
within 1 week
Consult to
Fetomaternal
Supervisor,
suggestion:
- Admitted to
the hospital
- Induction of
the labor
Sulfas ferrous
1x200mg
Kalk 1x1 tablet
Recontrolled
within 2 month
Sulfas ferrous
1x200mg
Kalk 1x1 tablet
Recontrolled
within 2 months

FCH-SUG

Z.34

Z.34

US

EVI

29

UA

US

WID

DWI

29

31

18 weeks gestational age SLF


intrauterine

G1P0A0 37 weeks gestational


age not inlabor SLF cephalic
presentation

G1P0A0 21 weeks gestational


age SLF intrauterine

US

18 weeks gestational age SLF


intrauterine
G1P0A0 23 weeks gestational
age SLF intrauterine

US

LACTATION AND PUERPURAL


No.
Initial
Age
Add

Z.34

Z.34

Z.34

23 weeks gestational age SLF


intrauterine

Diagnosis

37 weeks gestational age SLF


cephalic presentation with
amnion fluid thick and muddy
+ umbilical cord entanglement
1x

UA

UA

ICD Code

Treatment/Plan

CGH-ROD

FCH-SUG

CGH-ROD

FCH-SUG

Physician
5

1.

NUR

23

RA

P2A0 post LSCS due to


macrosemia day 13rd

082.1

Roborantia

ADS-??

YUL

23

UA

P2A0 post LSCS due to


macrosemia day 7th

082.1

Roborantia

ADS-??

Diagnosis

Contraception

P2A0 post
spontaneous
delivery (day 2)
O75.82
P2A0 post
spontaneous
delivery (day 1)
O75.82
P2A0 post
spontaneous
delivery (day 1)
O75.82
P1A0 post
spontaneous
delivery (day 1)
O75.82
P1A0 post
spontaneous
preterm delivery
(day 1)
O60.10
P1A0 post
spontaneous
delivery (day 1)
O75.82
P1A0 post
spontaneous
delivery (day 1)
O75.82
P1A0 post
spontaneous
delivery (day 2)
O75.82

Implant Insertion
Z30.49

ADS-SUG

IUD
Z97.5

ADS-SUG

Implant Insertion
Z30.49

ADS-SUG

Implant Insertion
Z30.49

ADS-SUG

Implant Insertion
Z30.49

ADS-SUG

IUD
Z97.5

ADS-SUG

IUD
Z97.5

ADS-SUG

IUD
Z97.5

ADS-SUG

FAMILY PLANNING
No.

Initial

Age

ERN

22

Status
(New/Old)/Date
April 24th 2015

SIT

26

April 24th 2015

VIT

27

April 24th 2015

WIW

20

April 24th 2015

SIN

20

April 27th 2015

NOV

28

April 27th 2015

ELS

19

April 27th 2015

SER

19

April 27th 2015

Physician