Rekapan KLPCM Perbulan

Catatan
Assesmen
Rekam Asuhan Assesmen Assesmen Ringkasan Pengkajian perkemba Catatan
Pasien Blanko Ringkasan Formulir Daftar Formulir Formulir
Medis keperawat Pasien Pasien Ceklist perawatan awal ngan awal Tindakan Evaluasi
Rawat Ceklist Masuk & perintah obat Skrining Pemberian
Ruang Gawat an IGD Rawat Rawat Transfer pasien medis pasien keperawat keperawat Keperawat
Jalan pasien Keluar lisan SBAR harian(RM. lanjut edukasi
Darurat(R (RMRD. Jalan Jalan Gigi Pasien pulang rawat inap terintegras an ranap an (RM13) an (RM08)
OBGYN poliklinik (RM01) (RM.04B) 06) (RM.04B1) (RM. 07)
MRD. 01) 02) (IRJ01) (IRJ03) (RM. 02) (RM. 05) i (RM. (RM. 03)
(IRJ02)
04A)
Y 32 32 1 0 0 0 32 47 48 49 49 1 46 36 19 49 49 49
N 3 3 1 0 0 0 4 3 2 1 1 0 4 0 0 0 0 0
NA 15 15 48 50 50 50 14 0 0 0 0 49 0 14 31 1 1 1
50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50
Y 64.0% 64.0% 2.0% 0.0% 0.0% 0.0% 64.0% 94.0% 96.0% 98.0% 98.0% 2.0% 92.0% 72.0% 38.0% 98.0% 98.0% 98.0%
N 6.0% 6.0% 2.0% 0.0% 0.0% 0.0% 8.0% 6.0% 4.0% 2.0% 2.0% 0.0% 8.0% 0.0% 0.0% 0.0% 0.0% 0.0%
NA 30.0% 30.0% 96.0% 100.0% 100.0% 100.0% 28.0% 0.0% 0.0% 0.0% 0.0% 98.0% 0.0% 28.0% 62.0% 2.0% 2.0% 2.0%
Catatan
Assesmen
(IRJ02)
04A)
Y 18 20 3 3 0 2 24 32 28 31 33 0 30 27 15 30 32 33
N 5 3 0 0 0 0 1 1 5 1 0 0 3 0 0 0 0 0
NA 10 10 30 30 33 30 8 0 0 1 0 33 0 6 18 3 1 0
33 33 33 33 33 32 33 33 33 33 33 33 33 33 33 33 33 33
Y 54.5% 60.6% 9.1% 9.1% 0.0% 6.3% 72.7% 97.0% 84.8% 93.9% 100.0% 0.0% 90.9% 81.8% 45.5% 90.9% 97.0% 100.0%
N 15.2% 9.1% 0.0% 0.0% 0.0% 0.0% 3.0% 3.0% 15.2% 3.0% 0.0% 0.0% 9.1% 0.0% 0.0% 0.0% 0.0% 0.0%
NA 30.3% 30.3% 90.9% 90.9% 100.0% 93.8% 24.2% 0.0% 0.0% 3.0% 0.0% 100.0% 0.0% 18.2% 54.5% 9.1% 3.0% 0.0%
Rencana Rencana
Rencana Rencana
Ringkasan Askep Rencana Askep Rencana
Rencana Rencana Rencana Rencana Askep Rencana Askep
pasien Rencana perubahan Askep perubahan Rencana Askep Rencana
Persetujua Askep Askep Askep Askep perubahan Askep perubahan
Formulir pulang, Lembaran Slip Askep perfusi perubahan nutrisi Askep gangguan Askep
n tindakan Kurang Kelebihan Penurunan Nyeri perfusi gangguan nutrisi
Vital Sign pindah, Konsul Kontrol Intoleransi jaringan perfusi kurang resiko komunikas hipertemia
pembiusan Volume Volume Curah akut/kroni jaringan mobilitas lebih dari
(RM.06B) atau (RM. 08) pasien OK aktifitas(R jantung perifer dari cidera(RM. i (RM.04.A1
(RM11) Cairan(RM. Cairan(RM. Jantung(R s(RM.04.A otak fisik(RM.0 kebutuhan
meninggal M.04.A4) paru (RM.04.A1 kebutuhan 04.A14) verbal(RM. 7)
04.A5) 04.A6) M.04.A7) 8) (RM.04.A1 4.A12) (RM.04.A1
(RM. 09) (RM.04.A9 1) (RM.04.A1 04.A15)
0) 6)
) 3)
50 50 5 15 0 9 1 0 0 16 0 1 0 0 5 0 0 0 6
0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0
0 0 45 34 50 41 49 50 50 34 50 49 50 50 45 47 50 50 44
50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 49 50 50 50
100.0% 100.0% 10.0% 30.0% 0.0% 18.0% 2.0% 0.0% 0.0% 32.0% 0.0% 2.0% 0.0% 0.0% 10.0% 0.0% 0.0% 0.0% 12.0%
0.0% 0.0% 0.0% 2.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.1% 0.0% 0.0% 0.0%
0.0% 0.0% 90.0% 68.0% 100.0% 82.0% 98.0% 100.0% 100.0% 68.0% 100.0% 98.0% 100.0% 100.0% 90.0% 95.9% 100.0% 100.0% 88.0%
Rencana Rencana
Rencana Rencana
04.A5) 04.A6) M.04.A7) 8) (RM.04.A1 4.A12) (RM.04.A1
(RM. 09) (RM.04.A9 1) (RM.04.A1 04.A15)
0) 6)
) 3)
33 31 2 16 0 6 1 0 0 10 0 0 0 1 0 0 0 0 2
0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 1 31 16 33 27 32 33 33 23 33 32 33 32 33 33 33 33 31
33 33 33 33 33 33 33 33 33 33 33 32 33 33 33 33 33 33 33
100.0% 93.9% 6.1% 48.5% 0.0% 18.2% 3.0% 0.0% 0.0% 30.3% 0.0% 0.0% 0.0% 3.0% 0.0% 0.0% 0.0% 0.0% 6.1%
0.0% 3.0% 0.0% 3.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
0.0% 3.0% 93.9% 48.5% 100.0% 81.8% 97.0% 100.0% 100.0% 69.7% 100.0% 100.0% 100.0% 97.0% 100.0% 100.0% 100.0% 100.0% 93.9%
Formulir
pelaporan
Rencana Rencana Rencana Rencana Rencana Rencana Rencana efek Rekonsilas
Rencana Rencana Rencana Rencana Rencana Rencana
Rencana Askep Askep Askep Rencana Askep Askep Rencana Askep Askep samping i obat dan
Askep Askep Askep Askep Askep Askep PK Skrining
Askep Inkontines gangguan kurang Askep gangguan gangguan askep resiko resiko obat daftar obat
hipotermia konstipasi( Retensio resiko harga diri CARSINOM gizi anak
diare(RM.0 ia integritas perawatan cemas(RM. integritas pola (RM.04.A3 jatuh pada jatuh pada panitia yg dibawa
(RM.04.A1 RM.04.A20 urine(RM.0 infeksi(RM rendah(RM A(RM.04.A (RM.04B)
4.A19) urin(RM.0 kulit(RM.0 diri(RM.04. 04.A26) jaringan(R tidur(RM.0 0) dewasa(R anak(RM.0 farmasi dari rumah
8) ) 4.A22) .04.A25) .04.A29) 33)
4.A21) 4.A23) A24) M.04.A27) 4.A28) M.04.A31) 4.A32) dan terapi (RM.06A)
(RM.05.A2
)
0 0 0 0 0 0 0 11 1 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
50 50 50 50 50 50 50 38 49 50 50 50 50 50 50 50 50 50 50
50 50 50 50 50 50 50 49 50 50 50 50 50 50 50 50 50 50 50
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 22.4% 2.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 77.6% 98.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Formulir
pelaporan
8) ) 4.A22) .04.A25) .04.A29) 33)
(RM.05.A2
)
0 0 0 0 0 0 0 6 1 0 0 0 0 1 1 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
33 33 33 33 33 33 33 27 32 33 33 33 33 32 32 33 33 33 33
33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 18.2% 3.0% 0.0% 0.0% 0.0% 0.0% 3.0% 3.0% 0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 81.8% 97.0% 100.0% 100.0% 100.0% 100.0% 97.0% 97.0% 100.0% 100.0% 100.0% 100.0%
Pengkajian
pengkjian Surat Identifikas Pengkajian
INDIKASI Catatan bayi baru Lembar
Pengkajian keperawat pengkajian Indikasi Permintaa Pernyataa Diagnosa Pengkajian i bayi Identitas asuhan
Pengkajian PASIEN Ners laporan lahir masa Observasi
keperawat an keperawat pasien n second Slip n Kronologis keperawat Nyeri diruang bayi kebidanan
resiko MASUK pasien persalinan transisi pasien
an PICU perinatolo an ICU keluar ICU opinion Kontrol persetujua laporan an Neonatus perinatolo pulang pada bayi
jatuh (RM. ICU pindah (RM dikamar kebidanan
(RM.07.1P gi (RMI09.IC (RMI09.4I (RM9.6ICU ICU n dirawat kematian (RM.10.1.1 (RM10.5P gi (RM10.7P baru lahir
07B) (RMI09.3I dari ruang 11KBD) bersalin/O (RM.18KB
ICU) (RM07.1P U) CU) ) diruang PRT) RT) (RM10.3P RT) (RM.18.1K
CU) ICU K D)
RT) ICU RT) BD)
(RM.14B)
0 15 0 2 2 2 0 0 0 1 0 13 0 1 12 1 8 1 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 2 0 0
50 35 50 48 48 48 50 50 50 49 50 36 50 49 36 49 40 49 49
50 50 50 50 50 50 50 50 50 50 50 49 50 50 50 50 50 50 50
0.0% 30.0% 0.0% 4.0% 4.0% 4.0% 0.0% 0.0% 0.0% 2.0% 0.0% 26.5% 0.0% 2.0% 24.0% 2.0% 16.0% 2.0% 2.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.0% 0.0% 4.0% 0.0% 0.0%
100.0% 70.0% 100.0% 96.0% 96.0% 96.0% 100.0% 100.0% 100.0% 98.0% 100.0% 73.5% 100.0% 98.0% 72.0% 98.0% 80.0% 98.0% 98.0%
Pengkajian
CU) ICU K D)
RT) ICU RT) BD)
(RM.14B)
0 6 0 0 0 0 0 0 0 0 0 5 0 0 6 0 5 2 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0
33 27 33 33 33 33 33 33 33 33 33 28 33 33 27 33 27 31 33
33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33
0.0% 18.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 15.2% 0.0% 0.0% 18.2% 0.0% 15.2% 6.1% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 3.0% 0.0% 0.0%
100.0% 81.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 84.8% 100.0% 100.0% 81.8% 100.0% 81.8% 93.9% 100.0%
Cheklist
Formulir keamanan Surat
Indikasi Indikasi Persetujua Permintaa
Lembar Penolakan cheklist pembedah Permintaa Surat pernyataa
Pasien pasien Surat Persalinan n/penolak Lembar Lembar Laporan Surat n dokter
Serah tindakan serah Kartu Slip Kamar an/prosed n dokter Pernyataa n
Masuk keluar Keteranga Normal an Anastesi Konsultasi Operasi Pengantar yang
Terima kedoktera terima Anastesi Bedah ur yang n APS permintaa
PICU/NIC PICU/NIC n Lahir Fartograf pemberian OK OK (RM.18) dirawat merawat
Bayi n (RM11B) pasien diagnostik merawat (RM21) n kelas
U U ASI (RM20)
(RM13) invasif (RM22)
(RM28)
0 0 0 1 0 0 0 9 13 2 0 13 14 11 0 1 0 1 0
0 0 0 0 0 0 0 3 4 0 0 1 3 3 0 0 0 0 0
50 50 50 48 50 50 50 38 33 48 50 36 33 36 50 49 50 49 50
50 50 50 49 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50
0.0% 0.0% 0.0% 2.0% 0.0% 0.0% 0.0% 18.0% 26.0% 4.0% 0.0% 26.0% 28.0% 22.0% 0.0% 2.0% 0.0% 2.0% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 6.0% 8.0% 0.0% 0.0% 2.0% 6.0% 6.0% 0.0% 0.0% 0.0% 0.0% 0.0%
100.0% 100.0% 100.0% 98.0% 100.0% 100.0% 100.0% 76.0% 66.0% 96.0% 100.0% 72.0% 66.0% 72.0% 100.0% 98.0% 100.0% 98.0% 100.0%
Cheklist
Formulir keamanan
Lembar Penolakan cheklist pembedah Permintaa Surat
Pasien pasien Surat Persalinan n/penolak Lembar Lembar Kamar Laporan Surat n dokter
Serah tindakan serah Kartu Slip Kamar an/prosed n dokter Pernyataa
Masuk keluar Keteranga Normal an Anastesi Konsultasi Bedah/An Operasi Pengantar yang
Terima kedoktera terima Anastesi Bedah ur yang n APS
PICU/NIC PICU/NIC n Lahir Fartograf pemberian OK OK estesi (RM.18) dirawat merawat
Bayi n (RM11B) pasien diagnostik merawat (RM21)
U U ASI (RM20)
(RM13) invasif
(RM28)
0 0 0 0 0 0 1 9 15 1 0 9 4 17 11 0 4 0 3
0 0 0 0 0 0 0 2 1 0 0 1 0 1 1 0 0 0 0
33 33 33 33 33 33 32 22 17 32 33 23 29 15 21 33 29 33 30
33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 3.0% 27.3% 45.5% 3.0% 0.0% 27.3% 12.1% 51.5% 33.3% 0.0% 12.1% 0.0% 9.1%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 6.1% 3.0% 0.0% 0.0% 3.0% 0.0% 3.0% 3.0% 0.0% 0.0% 0.0% 0.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.0% 66.7% 51.5% 97.0% 100.0% 69.7% 87.9% 45.5% 63.6% 100.0% 87.9% 100.0% 90.9%
General Form
Surat Form
Consent/P Pasien
Pernyataa Pasien
ersetujuan Pindah
n Tata pindah
Umum(RM Rumah
tertib ruangan
24) Sakit
50 50 1 1
0 0 0 0
0 0 49 49
50 50 50 50
100.0% 100.0% 2.0% 2.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 98.0% 98.0%
Surat
General Form
pernyataa Surat Form
Consent/P Pasien
n Pernyataa Pasien
ersetujuan Pindah
permintaa n Tata pindah
Umum(RM Rumah
n kelas tertib ruangan
24) Sakit
(RM22)
1 30 29 0 0
0 3 3 0 0
32 0 1 33 33
33 33 33 33 33
3.0% 90.9% 87.9% 0.0% 0.0%
0.0% 9.1% 9.1% 0.0% 0.0%
97.0% 0.0% 3.0% 100.0% 100.0%
Catatan
Assesmen
(IRJ02)
04A)
Y 17 18 5 2 0 0 19 24 26 27 27 0 24 22 12 27 27 27
N 1 0 0 0 0 0 2 3 2 0 0 0 2 1 1 0 0 0
NA 10 10 23 26 28 28 7 1 0 1 1 28 2 5 15 1 1 1
28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28
Y 60.7% 64.3% 17.9% 7.1% 0.0% 0.0% 67.9% 85.7% 92.9% 96.4% 96.4% 0.0% 85.7% 78.6% 42.9% 96.4% 96.4% 96.4%
N 3.6% 0.0% 0.0% 0.0% 0.0% 0.0% 7.1% 10.7% 7.1% 0.0% 0.0% 0.0% 7.1% 3.6% 3.6% 0.0% 0.0% 0.0%
NA 35.7% 35.7% 82.1% 92.9% 100.0% 100.0% 25.0% 3.6% 0.0% 3.6% 3.6% 100.0% 7.1% 17.9% 53.6% 3.6% 3.6% 3.6%
Catatan
Assesmen
(IRJ02)
04A)
Y 30 31 5 3 0 0 27 41 44 45 40 0 43 35 22 43 45 44
N 2 1 0 0 0 1 3 3 1 0 5 0 1 0 0 0 0 0
NA 13 13 40 42 45 44 14 1 0 0 0 45 1 10 23 2 0 1
45 45 45 45 45 45 44 45 45 45 45 45 45 45 45 45 45 45
Y 66.7% 68.9% 11.1% 6.7% 0.0% 0.0% 61.4% 91.1% 97.8% 100.0% 88.9% 0.0% 95.6% 77.8% 48.9% 95.6% 100.0% 97.8%
N 4.4% 2.2% 0.0% 0.0% 0.0% 2.2% 6.8% 6.7% 2.2% 0.0% 11.1% 0.0% 2.2% 0.0% 0.0% 0.0% 0.0% 0.0%
NA 28.9% 28.9% 88.9% 93.3% 100.0% 97.8% 31.8% 2.2% 0.0% 0.0% 0.0% 100.0% 2.2% 22.2% 51.1% 4.4% 0.0% 2.2%
Rencana Rencana
Rencana Rencana
04.A5) 04.A6) M.04.A7) 8) (RM.04.A1 4.A12) (RM.04.A1
(RM. 09) (RM.04.A9 1) (RM.04.A1 04.A15)
0) 6)
) 3)
27 26 2 9 0 4 1 0 0 11 1 0 0 0 0 0 0 0 1
0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1 1 26 18 28 24 27 28 28 17 27 28 28 28 28 28 28 28 27
28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28
96.4% 92.9% 7.1% 32.1% 0.0% 14.3% 3.6% 0.0% 0.0% 39.3% 3.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 3.6%
0.0% 3.6% 0.0% 3.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
3.6% 3.6% 92.9% 64.3% 100.0% 85.7% 96.4% 100.0% 100.0% 60.7% 96.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.4%
Rencana Rencana
Rencana Rencana
04.A5) 04.A6) M.04.A7) 8) (RM.04.A1 4.A12) (RM.04.A1
(RM. 09) (RM.04.A9 1) (RM.04.A1 04.A15)
0) 6)
) 3)
45 43 4 15 0 2 1 0 0 13 0 0 0 0 2 0 0 0 2
0 2 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 41 27 45 43 44 45 45 32 45 45 45 45 43 45 45 45 43
45 45 45 43 45 45 45 45 45 45 45 45 45 45 45 45 45 45 45
100.0% 95.6% 8.9% 34.9% 0.0% 4.4% 2.2% 0.0% 0.0% 28.9% 0.0% 0.0% 0.0% 0.0% 4.4% 0.0% 0.0% 0.0% 4.4%
0.0% 4.4% 0.0% 2.3% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 91.1% 62.8% 100.0% 95.6% 97.8% 100.0% 100.0% 71.1% 100.0% 100.0% 100.0% 100.0% 95.6% 100.0% 100.0% 100.0% 95.6%
Formulir
pelaporan
8) ) 4.A22) .04.A25) .04.A29) 33)
(RM.05.A2
)
0 0 0 0 0 0 0 2 1 0 0 0 0 2 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
28 28 28 28 28 28 28 26 27 28 28 28 28 26 28 28 28 28 28
28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.1% 3.6% 0.0% 0.0% 0.0% 0.0% 7.1% 0.0% 0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 92.9% 96.4% 100.0% 100.0% 100.0% 100.0% 92.9% 100.0% 100.0% 100.0% 100.0% 100.0%
Formulir
pelaporan
8) ) 4.A22) .04.A25) .04.A29) 33)
(RM.05.A2
)
0 0 0 0 0 0 0 3 2 0 0 0 0 1 0 0 0 0 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
45 45 45 45 45 45 45 42 43 45 45 45 45 44 45 44 45 45 44
45 45 45 45 45 45 45 45 45 45 45 45 45 45 45 44 45 45 45
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 6.7% 4.4% 0.0% 0.0% 0.0% 0.0% 2.2% 0.0% 0.0% 0.0% 0.0% 2.2%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 93.3% 95.6% 100.0% 100.0% 100.0% 100.0% 97.8% 100.0% 100.0% 100.0% 100.0% 97.8%
Pengkajian
CU) ICU K D)
RT) ICU RT) BD)
(RM.14B)
0 5 0 2 2 0 0 0 0 1 0 3 0 1 5 0 5 0 0
0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1
28 23 28 26 26 27 28 28 28 27 28 25 28 27 23 28 23 28 27
28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28
0.0% 17.9% 0.0% 7.1% 7.1% 0.0% 0.0% 0.0% 0.0% 3.6% 0.0% 10.7% 0.0% 3.6% 17.9% 0.0% 17.9% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0% 3.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 3.6%
100.0% 82.1% 100.0% 92.9% 92.9% 96.4% 100.0% 100.0% 100.0% 96.4% 100.0% 89.3% 100.0% 96.4% 82.1% 100.0% 82.1% 100.0% 96.4%
Pengkajian
CU) ICU K D)
RT) ICU RT) BD)
(RM.14B)
0 9 0 0 0 0 0 0 0 0 0 8 1 1 8 0 6 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0
45 35 45 45 45 45 45 45 45 45 45 37 44 44 36 45 38 45 45
45 44 45 45 45 45 45 45 45 45 45 45 45 45 45 45 45 45 45
0.0% 20.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 17.8% 2.2% 2.2% 17.8% 0.0% 13.3% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.2% 0.0% 2.2% 0.0% 0.0%
100.0% 79.5% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 82.2% 97.8% 97.8% 80.0% 100.0% 84.4% 100.0% 100.0%
Cheklist
U U ASI (RM20)
(RM28)
0 0 0 0 0 0 0 6 7 2 0 7 8 7 2 1 4 2 0
0 0 0 0 0 0 0 1 1 0 0 1 0 1 0 0 0 0 0
28 28 28 28 28 28 28 21 20 26 28 20 20 20 26 27 24 26 28
28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28 28
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 21.4% 25.0% 7.1% 0.0% 25.0% 28.6% 25.0% 7.1% 3.6% 14.3% 7.1% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 3.6% 3.6% 0.0% 0.0% 3.6% 0.0% 3.6% 0.0% 0.0% 0.0% 0.0% 0.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 75.0% 71.4% 92.9% 100.0% 71.4% 71.4% 71.4% 92.9% 96.4% 85.7% 92.9% 100.0%
Cheklist
U U ASI (RM20)
(RM28)
0 0 0 0 0 0 1 5 14 0 0 10 9 8 4 5 19 3 0
0 0 0 0 0 0 0 4 1 0 0 0 6 4 0 0 0 0 0
45 45 45 45 45 45 44 36 30 45 45 35 30 33 41 40 26 42 45
45 45 45 45 45 45 45 45 45 45 45 45 45 45 45 45 45 45 45
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.2% 11.1% 31.1% 0.0% 0.0% 22.2% 20.0% 17.8% 8.9% 11.1% 42.2% 6.7% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 8.9% 2.2% 0.0% 0.0% 0.0% 13.3% 8.9% 0.0% 0.0% 0.0% 0.0% 0.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.8% 80.0% 66.7% 100.0% 100.0% 77.8% 66.7% 73.3% 91.1% 88.9% 57.8% 93.3% 100.0%
General Form
Surat Form
Consent/P Pasien
Pernyataa Pasien
ersetujuan Pindah
n Tata pindah
Umum(RM Rumah
tertib ruangan
24) Sakit
28 28 0 0
0 0 0 0
0 0 28 28
28 28 28 28
100.0% 100.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 100.0% 100.0%
General Form
Surat Form
Consent/P Pasien
Pernyataa Pasien
ersetujuan Pindah
n Tata pindah
Umum(RM Rumah
tertib ruangan
24) Sakit
45 44 0 0
0 0 0 0
0 0 45 45
45 44 45 45
100.0% 100.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 100.0% 100.0%
Catatan
Assesmen
(IRJ02)
04A)
Y 46 56 5 0 0 1 56 64 67 71 69 4 70 64 26 73 74 70
N 13 3 1 0 0 0 3 10 7 3 5 0 4 1 0 0 0 0
NA 15 15 68 74 74 73 15 0 0 0 0 70 0 9 48 0 0 4
74 74 74 74 74 74 74 74 74 74 74 74 74 74 74 73 74 74
Y 62.2% 75.7% 6.8% 0.0% 0.0% 1.4% 75.7% 86.5% 90.5% 95.9% 93.2% 5.4% 94.6% 86.5% 35.1% 100.0% 100.0% 94.6%
N 17.6% 4.1% 1.4% 0.0% 0.0% 0.0% 4.1% 13.5% 9.5% 4.1% 6.8% 0.0% 5.4% 1.4% 0.0% 0.0% 0.0% 0.0%
NA 20.3% 20.3% 91.9% 100.0% 100.0% 98.6% 20.3% 0.0% 0.0% 0.0% 0.0% 94.6% 0.0% 12.2% 64.9% 0.0% 0.0% 5.4%
Catatan
Assesmen
Pasien Blanko Ringkasan Daftar Formulir Formulir
Medis keperawat Pasien Pasien Ceklist perawatan awal ngan awal Tindakan Evaluasi Formulir
Rawat Ceklist Masuk & obat Skrining Pemberian
Ruang Gawat an IGD Rawat Rawat Transfer pasien medis pasien keperawat keperawat Keperawat Vital Sign
Jalan pasien Keluar harian(RM. lanjut edukasi
Darurat(R (RMRD. Jalan Jalan Gigi Pasien pulang rawat inap terintegras an ranap an (RM13) an (RM08) (RM.06B)
OBGYN poliklinik (RM01) 06) (RM.04B1) (RM. 07)
(IRJ02)
04A)
Y 18 24 0 3 0 1 24 33 39 37 38 35 31 4 38 37 39 39
N 12 6 0 0 0 0 2 4 0 1 1 3 1 0 0 0 0 0
NA 9 9 39 36 39 38 13 2 0 1 0 1 7 35 1 2 0 0
39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39
Y 46.2% 61.5% 0.0% 7.7% 0.0% 2.6% 61.5% 84.6% 100.0% 94.9% 97.4% 89.7% 79.5% 10.3% 97.4% 94.9% 100.0% 100.0%
N 30.8% 15.4% 0.0% 0.0% 0.0% 0.0% 5.1% 10.3% 0.0% 2.6% 2.6% 7.7% 2.6% 0.0% 0.0% 0.0% 0.0% 0.0%
NA 23.1% 23.1% 100.0% 92.3% 100.0% 97.4% 33.3% 5.1% 0.0% 2.6% 0.0% 2.6% 17.9% 89.7% 2.6% 5.1% 0.0% 0.0%
Rencana Rencana
Rencana Rencana
04.A5) 04.A6) M.04.A7) 8) (RM.04.A1 4.A12) (RM.04.A1
(RM. 09) (RM.04.A9 1) (RM.04.A1 04.A15)
0) 6)
) 3)
74 70 11 19 1 9 1 0 0 23 0 3 0 1 1 0 0 0 13
0 2 1 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 2 62 53 73 65 73 74 74 51 74 71 74 73 73 74 74 74 61
74 74 74 74 74 74 74 74 74 74 74 74 74 74 74 74 74 74 74
100.0% 94.6% 14.9% 25.7% 1.4% 12.2% 1.4% 0.0% 0.0% 31.1% 0.0% 4.1% 0.0% 1.4% 1.4% 0.0% 0.0% 0.0% 17.6%
0.0% 2.7% 1.4% 2.7% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
0.0% 2.7% 83.8% 71.6% 98.6% 87.8% 98.6% 100.0% 100.0% 68.9% 100.0% 95.9% 100.0% 98.6% 98.6% 100.0% 100.0% 100.0% 82.4%
Rencana Rencana
Rencana Rencana
pasien Rencana perubahan Askep perubahan Rencana Askep Rencana Rencana
pulang, Lembaran Slip Askep perfusi perubahan nutrisi Askep gangguan Askep Askep
pindah, Konsul Kontrol Intoleransi jaringan perfusi kurang resiko komunikas hipertemia hipotermia
atau (RM. 08) pasien OK aktifitas(R jantung perifer dari cidera(RM. i (RM.04.A1 (RM.04.A1
meninggal M.04.A4) paru (RM.04.A1 kebutuhan 04.A14) verbal(RM. 7) 8)
04.A5) 04.A6) M.04.A7) 8) (RM.04.A1 4.A12) (RM.04.A1
(RM. 09) (RM.04.A9 1) (RM.04.A1 04.A15)
0) 6)
) 3)
38 2 18 0 9 0 0 0 18 0 0 0 1 2 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1 37 20 39 30 39 39 39 21 39 39 39 38 37 39 39 39 39 39
39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39
97.4% 5.1% 46.2% 0.0% 23.1% 0.0% 0.0% 0.0% 46.2% 0.0% 0.0% 0.0% 2.6% 5.1% 0.0% 0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 2.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
2.6% 94.9% 51.3% 100.0% 76.9% 100.0% 100.0% 100.0% 53.8% 100.0% 100.0% 100.0% 97.4% 94.9% 100.0% 100.0% 100.0% 100.0% 100.0%
Formulir
pelaporan
8) ) 4.A22) .04.A25) .04.A29) 33)
(RM.05.A2
)
1 0 0 0 0 1 0 11 1 0 0 0 0 0 0 0 0 0 3
0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0
73 74 74 74 74 73 74 62 73 74 74 74 74 74 74 74 74 74 71
74 74 74 74 74 74 74 74 74 74 74 74 74 74 74 74 74 74 74
1.4% 0.0% 0.0% 0.0% 0.0% 1.4% 0.0% 14.9% 1.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.1%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
98.6% 100.0% 100.0% 100.0% 100.0% 98.6% 100.0% 83.8% 98.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.9%
Formulir
pelaporan
Rencana Rencana Rencana Rencana Rencana Pengkajian
Askep Askep Askep Askep Askep PK Skrining keperawat
konstipasi( Retensio resiko harga diri CARSINOM gizi anak an PICU
RM.04.A20 urine(RM.0 infeksi(RM rendah(RM A(RM.04.A (RM.04B) (RM.07.1P
) 4.A22) .04.A25) .04.A29) 33) ICU)
(RM.05.A2
)
0 0 0 0 1 0 7 0 0 0 0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
39 39 39 39 38 39 32 39 39 39 39 39 39 39 39 39 39 38 39
39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39
0.0% 0.0% 0.0% 0.0% 2.6% 0.0% 17.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.6% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
100.0% 100.0% 100.0% 100.0% 97.4% 100.0% 82.1% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.4% 100.0%
Pengkajian
CU) ICU K D)
RT) ICU RT) BD)
(RM.14B)
0 11 0 2 2 2 0 0 0 3 1 6 0 0 9 2 6 0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
74 63 74 72 72 72 74 74 74 71 73 68 74 74 65 72 68 74 72
74 74 74 74 74 74 74 74 74 74 74 74 74 74 74 74 74 74 74
0.0% 14.9% 0.0% 2.7% 2.7% 2.7% 0.0% 0.0% 0.0% 4.1% 1.4% 8.1% 0.0% 0.0% 12.2% 2.7% 8.1% 0.0% 2.7%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
100.0% 85.1% 100.0% 97.3% 97.3% 97.3% 100.0% 100.0% 100.0% 95.9% 98.6% 91.9% 100.0% 100.0% 87.8% 97.3% 91.9% 100.0% 97.3%
Pengkajian
keperawat pengkajian Indikasi Permintaa Pernyataa Diagnosa Pengkajian i bayi Identitas asuhan Indikasi
an keperawat pasien n second Slip n Kronologis keperawat Nyeri diruang bayi kebidanan Pasien
perinatolo an ICU keluar ICU opinion Kontrol persetujua laporan an Neonatus perinatolo pulang pada bayi Masuk
gi (RMI09.IC (RMI09.4I (RM9.6ICU ICU n dirawat kematian (RM.10.1.1 (RM10.5P gi (RM10.7P baru lahir PICU/NIC
(RM07.1P U) CU) ) diruang PRT) RT) (RM10.3P RT) (RM.18.1K U
CU) ICU K D)
RT) ICU RT) BD)
(RM.14B)
6 0 0 0 0 0 0 0 0 0 4 0 0 8 1 5 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
33 39 39 39 39 39 39 38 39 39 35 39 39 31 38 34 39 39 39
39 39 39 39 39 39 39 38 39 39 39 39 39 39 39 39 39 39 39
15.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 10.3% 0.0% 0.0% 20.5% 2.6% 12.8% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
84.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 89.7% 100.0% 100.0% 79.5% 97.4% 87.2% 100.0% 100.0% 100.0%
Cheklist
U U ASI (RM20)
(RM28)
0 0 0 0 0 0 0 8 12 0 0 6 12 9 17 7 30 2 1
0 0 0 0 0 0 0 5 4 0 0 2 8 6 3 0 3 0 0
74 74 74 74 74 74 74 61 58 74 74 65 54 59 54 67 40 72 73
74 74 74 74 74 74 74 74 74 74 74 73 74 74 74 74 73 74 74
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 10.8% 16.2% 0.0% 0.0% 8.2% 16.2% 12.2% 23.0% 9.5% 41.1% 2.7% 1.4%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 6.8% 5.4% 0.0% 0.0% 2.7% 10.8% 8.1% 4.1% 0.0% 4.1% 0.0% 0.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 82.4% 78.4% 100.0% 100.0% 89.0% 73.0% 79.7% 73.0% 90.5% 54.8% 97.3% 98.6%
Cheklist
Indikasi Persetujua Permintaa General
Lembar Penolakan cheklist pembedah Surat pernyataa Surat
pasien Surat Persalinan n/penolak Lembar Lembar Laporan Surat n dokter Consent/P
Serah tindakan serah Kartu Slip Kamar an/prosed Pernyataa n Pernyataa
keluar Keteranga Normal an Anastesi Konsultasi Operasi Pengantar yang ersetujuan
Terima kedoktera terima Anastesi Bedah ur n APS permintaa n Tata
PICU/NIC n Lahir Fartograf pemberian OK OK (RM.18) dirawat merawat Umum(RM
Bayi n (RM11B) pasien diagnostik (RM21) n kelas tertib
U ASI (RM20) 24)
(RM28)
0 0 0 0 0 0 7 14 0 0 6 12 6 2 9 2 3 39 39
0 0 0 0 0 0 3 3 0 0 1 4 3 0 2 0 0 0 0
39 39 39 39 39 39 29 22 39 39 32 23 30 37 28 37 36 0 0
39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 17.9% 35.9% 0.0% 0.0% 15.4% 30.8% 15.4% 5.1% 23.1% 5.1% 7.7% 100.0% 100.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.7% 7.7% 0.0% 0.0% 2.6% 10.3% 7.7% 0.0% 5.1% 0.0% 0.0% 0.0% 0.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 74.4% 56.4% 100.0% 100.0% 82.1% 59.0% 76.9% 94.9% 71.8% 94.9% 92.3% 0.0% 0.0%
General Form
Surat Form
Consent/P Pasien
Pernyataa Pasien
ersetujuan Pindah
n Tata pindah
Umum(RM Rumah
tertib ruangan
24) Sakit
74 74 0 0
0 0 0 0
0 0 74 74
74 74 74 74
100.0% 100.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 100.0% 100.0%
Form
Form
Pasien
Pasien
Pindah
pindah
Rumah
ruangan
Sakit
0 0
0 0
39 39
39 39
0.0% 0.0%
0.0% 0.0%
100.0% 100.0%
Catatan
Assesmen
Medis keperawat Pasien Pasien Ceklist perawatan awal ngan awal Tindakan Evaluasi Formulir
Ruang Gawat an IGD Rawat Rawat Transfer pasien medis pasien keperawat keperawat Keperawat Vital Sign
Darurat(R (RMRD. Jalan Jalan Gigi Pasien pulang rawat inap terintegras an ranap an (RM13) an (RM08) (RM.06B)
(IRJ02)
04A)
Y 24 25 2 2 0 0 27 35 38 38 36 31 28 9 37 38 38 38
N 2 1 0 0 0 0 0 3 0 0 2 6 0 0 0 0 0 0
NA 12 12 36 36 38 38 11 0 0 0 0 1 10 29 1 0 0 0
38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38
Y 63.2% 65.8% 5.3% 5.3% 0.0% 0.0% 71.1% 92.1% 100.0% 100.0% 94.7% 81.6% 73.7% 23.7% 97.4% 100.0% 100.0% 100.0%
N 5.3% 2.6% 0.0% 0.0% 0.0% 0.0% 0.0% 7.9% 0.0% 0.0% 5.3% 15.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
NA 31.6% 31.6% 94.7% 0.0% 100.0% 100.0% 28.9% 0.0% 0.0% 0.0% 0.0% 2.6% 26.3% 76.3% 2.6% 0.0% 0.0% 0.0%
Catatan Ringkasan
Assesmen
Rekam Asuhan Assesmen Assesmen Ringkasan Pengkajian perkemba Catatan pasien
Medis keperawat Pasien Pasien Ceklist perawatan awal ngan awal Evaluasi Formulir pulang,
Ruang Gawat an IGD Rawat Rawat Transfer pasien medis pasien keperawat Keperawat Vital Sign pindah,
Darurat(R (RMRD. Jalan Jalan Gigi Pasien pulang rawat inap terintegras an ranap an (RM08) (RM.06B) atau
MRD. 01) 02) (IRJ01) (IRJ03) (RM. 02) (RM. 05) i (RM. (RM. 03) meninggal
(IRJ02)
04A) (RM. 09)
Y 21 23 4 0 0 0 25 31 32 32 31 29 25 6 30 32 31 28
N 5 3 1 1 1 1 0 1 0 0 1 0 1 0 0 0 0 0
NA 6 6 27 31 31 31 7 0 0 0 0 3 6 26 2 0 0 4
32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 31 32
Y 66% 72% 13% 0% 0% 0% 78% 97% 100% 100% 97% 91% 78% 19% 94% 100% 100% 88%
N 16% 9% 3% 3% 3% 3% 0% 3% 0% 0% 3% 0% 3% 0% 0% 0% 0% 0%
NA 19% 19% 84% 97% 97% 97% 22% 0% 0% 0% 0% 9% 19% 81% 6% 0% 0% 13%
Rencana Rencana
Rencana Rencana
pasien Rencana perubahan Askep perubahan Rencana Askep Rencana Rencana
pulang, Lembaran Slip Askep perfusi perubahan nutrisi Askep gangguan Askep Askep
pindah, Konsul Kontrol Intoleransi jaringan perfusi kurang resiko komunikas hipertemia hipotermia
atau (RM. 08) pasien OK aktifitas(R jantung perifer dari cidera(RM. i (RM.04.A1 (RM.04.A1
meninggal M.04.A4) paru (RM.04.A1 kebutuhan 04.A14) verbal(RM. 7) 8)
04.A5) 04.A6) M.04.A7) 8) (RM.04.A1 4.A12) (RM.04.A1
(RM. 09) (RM.04.A9 1) (RM.04.A1 04.A15)
0) 6)
) 3)
35 7 13 0 8 1 1 0 9 0 0 0 1 1 0 0 0 2 0
3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 31 25 38 30 37 37 38 29 38 38 38 37 37 38 38 38 36 38
38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38
92.1% 18.4% 34.2% 0.0% 21.1% 2.6% 2.6% 0.0% 23.7% 0.0% 0.0% 0.0% 2.6% 2.6% 0.0% 0.0% 0.0% 5.3% 0.0%
7.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
0.0% 81.6% 65.8% 100.0% 78.9% 97.4% 97.4% 100.0% 76.3% 100.0% 100.0% 100.0% 97.4% 97.4% 100.0% 100.0% 100.0% 94.7% 100.0%
Rencana Rencana
Rencana Rencana
Askep Rencana Askep Rencana
Rencana perubahan Askep perubahan Rencana Askep Rencana Rencana
Lembaran Tindakan Slip Askep perfusi perubahan nutrisi Askep gangguan Askep Askep
Konsul keperawat Kontrol Intoleransi jaringan perfusi kurang resiko komunikas hipertemia hipotermia
(RM. 08) an (RM13) pasien OK aktifitas(R jantung perifer dari cidera(RM. i (RM.04.A1 (RM.04.A1
M.04.A4) paru (RM.04.A1 kebutuhan 04.A14) verbal(RM. 7) 8)
04.A5) 04.A6) M.04.A7) 8) (RM.04.A1 4.A12) (RM.04.A1
(RM.04.A9 1) (RM.04.A1 04.A15)
0) 6)
) 3)
4 8 28 0 2 0 0 0 12 0 0 0 0 2 0 0 0 2 0
0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
28 22 4 32 30 32 32 32 20 32 32 32 32 30 32 32 32 30 32
32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32
13% 25% 88% 0% 6% 0% 0% 0% 38% 0% 0% 0% 0% 6% 0% 0% 0% 6% 0%
0% 6% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
88% 69% 13% 100% 94% 100% 100% 100% 63% 100% 100% 100% 100% 94% 100% 100% 100% 94% 100%
Formulir
pelaporan
) 4.A22) .04.A25) .04.A29) 33) ICU)
(RM.05.A2
)
2 0 0 0 0 0 3 1 0 0 0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0
36 38 38 38 38 38 35 37 38 38 38 38 38 38 38 38 38 35 38
38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38
5.3% 0.0% 0.0% 0.0% 0.0% 0.0% 7.9% 2.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.6% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 5.3% 0.0%
94.7% 100.0% 100.0% 100.0% 100.0% 100.0% 92.1% 97.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 92.1% 100.0%
Formulir
pelaporan
) 4.A22) .04.A25) .04.A29) 33) ICU)
(RM.05.A2
)
1 0 0 0 0 0 1 0 0 0 0 0 0 3 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0
31 32 32 32 32 32 31 32 32 32 32 32 32 29 32 32 32 31 32
32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32
3% 0% 0% 0% 0% 0% 3% 0% 0% 0% 0% 0% 0% 9% 0% 0% 0% 0% 0%
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 3% 0%
97% 100% 100% 100% 100% 100% 97% 100% 100% 100% 100% 100% 100% 91% 100% 100% 100% 97% 100%
Pengkajian
CU) ICU K D)
RT) ICU RT) BD)
(RM.14B)
6 0 0 0 0 0 0 0 0 0 8 0 0 8 0 9 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0
32 38 38 38 38 38 38 38 38 38 30 38 38 29 38 29 38 38 37
38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 38 37
15.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 21.1% 0.0% 0.0% 21.1% 0.0% 23.7% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.6% 0.0% 0.0% 0.0% 0.0% 0.0%
84.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 78.9% 100.0% 100.0% 76.3% 100.0% 76.3% 100.0% 100.0% 100.0%
Pengkajian
CU) ICU K D)
RT) ICU RT) BD)
(RM.14B)
5 0 0 0 0 0 0 0 0 0 4 0 0 3 0 3 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
27 32 32 32 32 32 32 32 32 32 28 32 32 29 32 29 32 32 32
32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32
16% 0% 0% 0% 0% 0% 0% 0% 0% 0% 13% 0% 0% 9% 0% 9% 0% 0% 0%
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
84% 100% 100% 100% 100% 100% 100% 100% 100% 100% 88% 100% 100% 91% 100% 91% 100% 100% 100%
Cheklist
U ASI (RM20) 24)
(RM28)
0 0 0 0 0 0 9 12 0 0 9 11 7 2 19 2 0 38 38
0 0 0 0 0 0 1 0 0 0 0 1 2 0 2 0 0 0 0
37 38 38 38 38 38 28 26 38 38 29 26 28 36 16 36 37 0 0
37 38 38 38 38 38 38 38 38 38 38 38 37 38 37 38 37 38 38
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 23.7% 31.6% 0.0% 0.0% 23.7% 28.9% 18.9% 5.3% 51.4% 5.3% 0.0% 100.0% 100.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.6% 0.0% 0.0% 0.0% 0.0% 2.6% 5.4% 0.0% 5.4% 0.0% 0.0% 0.0% 0.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 73.7% 68.4% 100.0% 100.0% 76.3% 68.4% 75.7% 94.7% 43.2% 94.7% 100.0% 0.0% 0.0%
Cheklist
U ASI (RM20) 24)
(RM28)
0 0 0 0 0 2 4 4 0 0 7 9 6 1 16 0 0 32 32
0 0 0 0 0 0 3 4 0 0 0 1 1 0 3 0 0 0 0
32 32 32 32 32 30 25 24 32 32 25 22 25 31 13 32 32 0 0
32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32
0% 0% 0% 0% 0% 6% 13% 13% 0% 0% 22% 28% 19% 3% 50% 0% 0% 100% 100%
0% 0% 0% 0% 0% 0% 9% 13% 0% 0% 0% 3% 3% 0% 9% 0% 0% 0% 0%
100% 100% 100% 100% 100% 94% 78% 75% 100% 100% 78% 69% 78% 97% 41% 100% 100% 0% 0%
Form
Form
Pasien
Pasien
Pindah
pindah
Rumah
ruangan
Sakit
0 0
0 0
38 38
38 38
0.0% 0.0%
0.0% 0.0%
100.0% 100.0%
Form
Form
Pasien
Pasien
Pindah
pindah
Rumah
ruangan
Sakit
0 0
0 0
32 32
32 32
0% 0%
0% 0%
100% 100%
Catatan
Assesmen
Pasien Blanko Ringkasan Daftar Formulir
Medis keperawat Pasien Pasien Ceklist perawatan awal ngan awal Tindakan
Rawat Ceklist Masuk & obat Skrining
Ruang Gawat an IGD Rawat Rawat Transfer pasien medis pasien keperawat keperawat
Jalan pasien Keluar harian(RM. lanjut
Darurat(R (RMRD. Jalan Jalan Gigi Pasien pulang rawat inap terintegras an ranap an (RM13)
OBGYN poliklinik (RM01) 06) (RM.04B1)
(IRJ02)
04A)
Y 30 41 6 3 1 1 46 53 53 53 54 50 42 9 53
N 20 8 0 0 0 0 0 6 5 2 4 6 0 0 0
NA 9 10 53 56 58 58 13 0 1 4 1 3 17 50 6
59 59 59 59 59 59 59 59 59 59 59 59 59 59 59
Y 51% 69% 10% 5% 2% 2% 78% 90% 90% 90% 92% 85% 71% 15% 90%
N 34% 14% 0% 0% 0% 0% 0% 10% 8% 3% 7% 10% 0% 0% 0%
NA 15% 17% 90% 95% 98% 98% 22% 0% 2% 7% 2% 5% 29% 85% 10%
KET : Y = LENGKAP
N = TIDAK LENGKAP
NA = TIDAK ADA
Rencana Rencana
Rencana
Ringkasan Askep Rencana Askep
Rencana Rencana Rencana Rencana Askep Rencana
pasien Rencana perubahan Askep perubahan
Formulir Persetujua Askep Askep Askep Askep perubahan Askep
Evaluasi Formulir pulang, Lembaran Slip Askep perfusi perubahan nutrisi
Pemberian n tindakan Kurang Kelebihan Penurunan Nyeri perfusi gangguan
Keperawat Vital Sign pindah, Konsul Kontrol Intoleransi jaringan perfusi kurang
edukasi pembiusan Volume Volume Curah akut/kroni jaringan mobilitas
an (RM08) (RM.06B) atau (RM. 08) pasien OK aktifitas(R jantung perifer dari
(RM. 07) (RM11) Cairan(RM. Cairan(RM. Jantung(R s(RM.04.A otak fisik(RM.0
meninggal M.04.A4) paru (RM.04.A1 kebutuhan
04.A5) 04.A6) M.04.A7) 8) (RM.04.A1 4.A12)
(RM. 09) (RM.04.A9 1) (RM.04.A1
0)
) 3)
53 54 58 54 2 15 0 7 2 1 0 17 0 0 0 0 5
0 4 0 5 1 0 0 0 0 0 0 0 0 0 0 0 0
6 1 1 0 56 44 59 52 57 58 59 42 59 59 59 59 54
59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59
90% 92% 98% 92% 3% 25% 0% 12% 3% 2% 0% 29% 0% 0% 0% 0% 8%
0% 7% 0% 8% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
10% 2% 2% 0% 95% 75% 100% 88% 97% 98% 100% 71% 100% 100% 100% 100% 92%
Rencana
Rencana
Askep Rencana Rencana Rencana Rencana Rencana
Rencana Askep Rencana Rencana Rencana Rencana Rencana Rencana
perubahan Rencana Askep Askep Askep Rencana Askep Askep Rencana
Askep gangguan Askep Askep Askep Askep Askep Askep
nutrisi Askep Inkontines gangguan kurang Askep gangguan gangguan askep
resiko komunikas hipertemia hipotermia konstipasi( Retensio resiko harga diri
lebih dari diare(RM.0 ia integritas perawatan cemas(RM. integritas pola (RM.04.A3
cidera(RM. i (RM.04.A1 (RM.04.A1 RM.04.A20 urine(RM.0 infeksi(RM rendah(RM
kebutuhan 4.A19) urin(RM.0 kulit(RM.0 diri(RM.04. 04.A26) jaringan(R tidur(RM.0 0)
04.A14) verbal(RM. 7) 8) ) 4.A22) .04.A25) .04.A29)
(RM.04.A1 4.A21) 4.A23) A24) M.04.A27) 4.A28)
04.A15)
6)
0 0 0 7 0 1 0 0 0 1 0 6 1 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
59 59 59 52 59 58 59 59 59 58 59 53 58 59 59 59 59
59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59
0% 0% 0% 12% 0% 2% 0% 0% 0% 2% 0% 10% 2% 0% 0% 0% 0%
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
100% 100% 100% 88% 100% 98% 100% 100% 100% 98% 100% 90% 98% 100% 100% 100% 100%
Formulir
pelaporan
pengkjian Surat
Rencana Rencana efek Rekonsilas INDIKASI Catatan
Rencana Pengkajian keperawat pengkajian Indikasi Permintaa Pernyataa
Askep Askep samping i obat dan Pengkajian PASIEN Ners
Askep PK Skrining keperawat an keperawat pasien n second Slip n Kronologis
resiko resiko obat daftar obat resiko MASUK pasien
CARSINOM gizi anak an PICU perinatolo an ICU keluar ICU opinion Kontrol persetujua laporan
jatuh pada jatuh pada panitia yg dibawa jatuh (RM. ICU pindah
A(RM.04.A (RM.04B) (RM.07.1P gi (RMI09.IC (RMI09.4I (RM9.6ICU ICU n dirawat kematian
dewasa(R anak(RM.0 farmasi dari rumah 07B) (RMI09.3I dari ruang
33) ICU) (RM07.1P U) CU) ) diruang
M.04.A31) 4.A32) dan terapi (RM.06A) CU) ICU
RT) ICU
(RM.05.A2
)
0 0 0 0 0 4 0 10 0 2 1 1 0 0 0 2 1
0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0
59 59 59 59 59 54 59 49 59 57 57 57 59 59 59 57 58
59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59
0% 0% 0% 0% 0% 7% 0% 17% 0% 3% 2% 2% 0% 0% 0% 3% 2%
0% 0% 0% 0% 0% 2% 0% 0% 0% 0% 2% 2% 0% 0% 0% 0% 0%
100% 100% 100% 100% 100% 92% 100% 83% 100% 97% 97% 97% 100% 100% 100% 97% 98%
Pengkajian
Identifikas Pengkajian
bayi baru Lembar
Diagnosa Pengkajian i bayi Identitas asuhan Indikasi Indikasi Persetujua
laporan lahir masa Observasi Lembar Penolakan
keperawat Nyeri diruang bayi kebidanan Pasien pasien Surat Persalinan n/penolak
persalinan transisi pasien Serah tindakan
an Neonatus perinatolo pulang pada bayi Masuk keluar Keteranga Normal an
(RM dikamar kebidanan Terima kedoktera
(RM.10.1.1 (RM10.5P gi (RM10.7P baru lahir PICU/NIC PICU/NIC n Lahir Fartograf pemberian
11KBD) bersalin/O (RM.18KB Bayi n (RM11B)
PRT) RT) (RM10.3P RT) (RM.18.1K U U ASI
K D)
RT) BD)
(RM.14B)
2 0 0 6 0 7 0 0 0 0 0 0 0 0 0
0 0 0 0 0 2 0 0 0 0 0 0 0 0 0
57 59 59 53 59 50 59 59 59 59 59 59 59 59 59
59 59 59 59 59 59 59 59 59 59 59 59 59 59 59
3% 0% 0% 10% 0% 12% 0% 0% 0% 0% 0% 0% 0% 0% 0%
0% 0% 0% 0% 0% 3% 0% 0% 0% 0% 0% 0% 0% 0% 0%
97% 100% 100% 90% 100% 85% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Cheklist
Permintaa General Form
cheklist pembedah Surat pernyataa Surat Form
Lembar Lembar Laporan Surat n dokter Consent/P Pasien
serah Kartu Slip Kamar an/prosed Pernyataa n Pernyataa Pasien
Anastesi Konsultasi Operasi Pengantar yang ersetujuan Pindah
terima Anastesi Bedah ur n APS permintaa n Tata pindah
OK OK (RM.18) dirawat merawat Umum(RM Rumah
pasien diagnostik (RM21) n kelas tertib ruangan
(RM20) 24) Sakit
(RM28)
10 15 0 0 9 9 8 5 23 1 0 59 59 1 2
0 0 0 0 1 6 3 0 5 1 0 0 0 0 0
49 44 59 59 49 44 48 54 31 57 59 0 0 58 57
59 59 59 59 59 59 59 59 59 59 59 59 59 59 59
17% 25% 0% 0% 15% 15% 14% 8% 39% 2% 0% 100% 100% 2% 3%
0% 0% 0% 0% 2% 10% 5% 0% 8% 2% 0% 0% 0% 0% 0%
83% 75% 100% 100% 83% 75% 81% 92% 53% 97% 100% 0% 0% 98% 97%

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