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  • Tugas Review MCN 1

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    HERI TEMO
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    The document reviews the identification of inpatients at Sambungmacan 1 Community Health Center in October 2017. It analyzes 17 patient records across 9 categories to check for completeness of information like name, address, gender, age, religion, as well as signatures and clarity of writing. The review found all items in the 17 records to be 100% complete and clear except for nursing notes and treatment plans, which had 5 incomplete or unclear records each.

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    Tugas Review mcn 1

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    The document reviews the identification of inpatients at Sambungmacan 1 Community Health Center in October 2017. It analyzes 17 patient records across 9 categories to check for completeness of information like name, address, gender, age, religion, as well as signatures and clarity of writing. The review found all items in the 17 records to be 100% complete and clear except for nursing notes and treatment plans, which had 5 incomplete or unclear records each.

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    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
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    8 views9 pages

    Tugas Review MCN 1

    Uploaded by

    HERI TEMO
    The document reviews the identification of inpatients at Sambungmacan 1 Community Health Center in October 2017. It analyzes 17 patient records across 9 categories to check for completeness of information like name, address, gender, age, religion, as well as signatures and clarity of writing. The review found all items in the 17 records to be 100% complete and clear except for nursing notes and treatment plans, which had 5 incomplete or unclear records each.

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    © All Rights Reserved
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    of 9

    REVIEW IDENTIFIKASI PASIEN

    PASIEN UMUM RAWAT INAP PUSKESMAS SAMBUNGMACAN 1


    BULAN OKTOBER 2017

    ITEM YANG DI TELITI


    JENIS
    NO NO RM NAMA ALAMAT RUANG JENIS KELAMIN UMUR
    FORMULIR
    L % TL % L % TL % L % TL % L % TL % L % TL % L % TL %

    1 Lembar Masuk & 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0


    Keluar

    2 Perjalanan 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0


    Penyakit

    Catatan Perawat
    3 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0
    ttg obat

    Rekam Asuhan
    4 Keperawatan 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0

    Asuhan
    5 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0
    Keperawatan
    6 Grafik 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0

    7 Hasil
    Pemeriksaan Lab 17
    100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0

    Persetujuan
    8 Tindakan Medis 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0

    9 Resume 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0 17 100 0 0


    NTIFIKASI PASIEN
    P PUSKESMAS SAMBUNGMACAN 1
    OKTOBER 2017

    ITEM YANG DI TELITI


    AGAMA HASIL
    L % TL % L TL

    17 100 0 0 17 0

    17 100 0 0 17 0

    17 100 0 0 17 0

    17 100 0 0 17 0

    17 100 0 0 17 0

    17 100 0 0 17 0

    17 100 0 0 17 0

    17 100 0 0 17 0

    17 100 0 0 17 0
    REVIEW PELAPORAN
    PASIEN UMUM RAWAT JALAN PUSKESMAS JETAK
    BULAN OKTOBER 2017

    ITEM REVIEW PELAPORAN


    NO JENIS FORMULIR Tanggal Laporan Yang Harusnya ada HASIL
    L % TL % L % TL % L TL
    1 FORMULIR RAWAT JALAN
    2
    3
    4
    5
    6
    7
    8
    9

    NAMA : HERI WIJI YATMOKO


    NIM : 2017330
    DOSEN : BU. NOVITA
    REVIEW AUTENTIFIKASI
    PASIEN UMUM RAWAT INAP PUSKESMAS SAMBUNGMACAN 1
    BULAN OKTOBER 2017

    ITEM REVIEW AUTENTIFIKASI


    NO JENIS FORMULIR TANDA TANGAN NAMA TERANG HASIL
    L % TL % L % TL % L
    1 FORMULIR RAWAT JALAN 17 100 0 0 17 100 0 0 17
    2 Perjalanan Penyakit 17 100 0 0 17 100 0 0 17
    3 Catatan Perawat ttg obat 17 100 0 0 17 100 0 0 17
    4 Rekam Asuhan Keperawatan 17 100 0 0 17 100 0 0 17
    5 Asuhan Keperawatan 17 100 0 0 17 100 0 0 17
    6 Grafik 17 100 0 0 17 100 0 0 17
    7 Hasil Pemeriksaan Lab 17 100 0 0 17 100 0 0 17
    8 Persetujuan Tindakan Medis 17 100 0 0 17 100 0 0 17
    9 Resume 17 100 0 0 17 100 0 0 17
    W AUTENTIFIKASI
    AP PUSKESMAS SAMBUNGMACAN 1
    OKTOBER 2017

    ITEM REVIEW AUTENTIFIKASI


    HASIL
    TL
    0
    0
    0
    0
    0
    0
    0
    0
    0
    REVIEW PENCATATAN
    PASIEN UMUM RAWAT INAP PUSKESMAS SAMBUNGMACAN 1
    BULAN OKTOBER 2017

    ITEM REVIEW PENCATATAN


    NO JENIS FORMULIR Simbol singkatan tidak baku Coretan tanpa paraf Cara Pengha
    L % TL % L % TL % L %
    1 Lembar Masuk & Keluar 17 100 0 0 17 100 0 0 17 100
    2 Perjalanan Penyakit 17 100 0 0 17 100 0 0 17 100
    3 Catatan Perawat ttg obat 17 100 0 0 17 100 0 0 17 100
    4 Rekam Asuhan Keperawatan 17 100 0 0 10 100 5 29% 10 100
    5 Asuhan Keperawatan 17 100 0 0 10 100 5 29% 10 100
    6 Grafik 17 100 0 0 17 100 0 0 17 100
    7 Hasil Pemeriksaan Lab 17 100 0 0 17 100 0 0 17 100
    8 Persetujuan Tindakan Medis 17 100 0 0 15 100 2 12% 15 100
    9 Resume 17 100 0 0 17 100 0 0 17 100
    PENCATATAN
    PUSKESMAS SAMBUNGMACAN 1
    KTOBER 2017

    ITEM REVIEW PENCATATAN


    Cara Penghapusan HASIL
    TL % L TL
    0 0 17 0
    0 0 17 0
    0 0 17 0
    5 29% 10 5
    5 29% 10 5
    0 0 17 0
    0 0 17 0
    2 12% 15 2
    0 0 17 0
    REVIEW LAPORAN

    ITEM PADA REVIEW PELAPORAN


    NAMA
    NO Tanggal Jam
    FORMULIR
    L % TL % L % TL %
    Lembar
    1 Masuk &
    Keluar

    2 Riwayat
    Penyakit

    3 Perjalanan
    Penyakit
    Catatan
    4 Perawat ttg
    obat

    Rekam
    5 Asuhan
    Keperawatan

    Asuhan
    6
    Keperawatan

    7 Grafik
    Hasil
    8 Pemeriksaan
    Lab

    Lembar
    Bukti
    9
    Tindakan
    Keperawatan

    Persetujuan
    10 Tindakan
    Medis
    11 Resume
    RAN HASIL
    Laporan Yang Harusnya ada
    L TL
    L % TL %

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