MR.

3/I
CLINICAL PATHWAYS
RSI IBNU SINA
MAKASSAR
SMF : ILMU PENYAKIT SARAF

Nama Pasien : Tgl Lahir : Berat Badan : Tinggi Badan : No. Rekam Medis :
............................................................ ......................... ................. kg ................. cm
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Diagnosis Awal Kode ICD 10 : (ICD .164) Rencana rawat : 3hari
:....................................
Aktivitas R. Rawat Tgl/Jam masuk : Tgl/Jam keluar Lama Rwt Kelas : Tarif/hr (Rp): Biaya(Rp)
Pelayanan ................... .......................... .................. .......... hari ............ .................. ................
Admisi Rawat Inap
IGD IRJ HR HR HR
1 2 3
Diagnosis :
Penyakit Utama Neuralgia Trigeminal
Penyakit Penyerta
Hipertensi +/- +/- +/- +/- +/-
Common cold +/- +/- +/- +/- +/-
Psikosomatik +/- +/- +/- +/- +/-
Herpez +/- +/- +/- +/- +/-
Stimulasi dingin +/- +/- +/- +/- +/-
Varicella +/- +/- +/- +/- +/-
Komplikasi
Disfagia +/- +/- +/- +/- +/-
Gangguan Nn cr +/- +/- +/- +/- +/-
Insomnia +/- +/- +/- +/- +/-

Asesmen Klinis :
Pemeriksaan dokter
Konsultasi :
Internist +/- +/- +/- +/- +/-
Anastesiologi +/- +/- +/- +/- +/-
Psikiater +/- +/- +/- +/- +/-
Kul-Kel +/- +/- +/- +/- +/-
Gigi Mulut +/- +/- +/- +/- +/-
Pem,Penunjang:
Pem. Laboratorium +/- +/- +/- +/- +/-
Foto Polos +/- +/- +/- +/- +/-
EMNG +/- +/- +/- +/- +/-
CT-Scan +/- +/- +/- +/- +/-
Tindakan :
Lidokain topikal +/- +/- +/- +/- +/-
Operasi +/- +/- +/- +/- +/-C
....................
Obat-Obatan :
Paracetamol +/- +/- +/- +/- +/-
NSAID +/- +/- +/- +/- +/-
Diazepam +/- +/- +/- +/- +/-
TCA +/- +/- +/- +/- +/-
Cafein +/- +/- +/- +/- +/-
Neuroboransia +/- +/- +/- +/- +/-

Pembiusan Umum Gas:

....................
.................... +/- +/- +/- +/- +/-
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+/- +/- +/- +/- +/-
+/- +/- +/- +/- +/-
Pembiusan UmumInjeksi:
....................
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.................... +/- +/- +/- +/- +/-
+/- +/- +/- +/- +/-
Pembiusan Regional/Lokal: +/- +/- +/- +/- +/-
Lidokain HCL
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+/- +/- +/- +/- +/-

+/- +/- +/- +/- +/-
+/- +/- +/- +/- +/-

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 MR.3/I

Nutrisi: +/- +/- +/- +/- +/-

35 40kkal/KgBB/hr +/- +/- +/- +/- +/-
Protein... gram/hr

Mobilisasi:
Duduk +/- +/- +/- +/- +/-
Berdiri +/- +/- +/- +/- +/-
Berjalan +/- +/- +/- +/- +/-
Hasil (Outcome):
Sembuh Sempurna +/- +/- +/- +/- +/-
Sembuh dg Sekuele +/- +/- +/- +/- +/-
Meninggal +/- +/- +/- +/- +/-
Pendidikan/Promosi
Kesehatan/Rencana
Pemulangan :
Pasien +/- +/- +/- +/- +/-
Keluarga Pasien +/- +/- +/- +/- +/-
.................... +/- +/- +/- +/- +/-
Varians :
Jumlah Biaya
Perawat (PPJP) Diagnosis Akhir : Kode ICD 10 Jenis Tindakan Kode ICD 9 – CM
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DPJP Admisi :  ...................................... ................................
 Utama .................................. ....................
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DPJP :  Penyerta ................................... ....................  ...................................... ................................
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DPJP Operasi : ...... ....................  ...................................... ................................
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DPJP Anestesi Komplikasi ................................... .....................  ......................................
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Verifikator:  ...................................... ................................
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