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    KARDEK

    Uploaded by

    yayan
    This document summarizes the intensive care chart of a patient over a 24 hour period, including vital signs monitored every hour, treatments, medications, inputs and outputs. It records medical devices used, diagnoses, doctors in charge of care, and notes from nursing and medical staff.

    Copyright:

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

    KARDEK

    Uploaded by

    yayan
    144 views44 pages
    This document summarizes the intensive care chart of a patient over a 24 hour period, including vital signs monitored every hour, treatments, medications, inputs and outputs. It records medical devices used, diagnoses, doctors in charge of care, and notes from nursing and medical staff.

    Original Description:

    kardex

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    This document summarizes the intensive care chart of a patient over a 24 hour period, including vital signs monitored every hour, treatments, medications, inputs and outputs. It records medical devices used, diagnoses, doctors in charge of care, and notes from nursing and medical staff.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    144 views44 pages

    KARDEK

    Uploaded by

    yayan
    This document summarizes the intensive care chart of a patient over a 24 hour period, including vital signs monitored every hour, treatments, medications, inputs and outputs. It records medical devices used, diagnoses, doctors in charge of care, and notes from nursing and medical staff.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 44
    At a glance
    Powered by AI
    This appears to be a medical record documenting a patient's condition and treatment over multiple days in the intensive care unit (ICU).

    The document is an ICU chart used to record a patient's vital signs, treatments, intake/output, notes from nurses and doctors, and other medical information during their stay in the ICU.

    Each page records things like vital signs, medications, procedures, notes for different time periods (hours of the day).

    RUMAH SAKIT UMUM PROKLAMASI JL.

    Tanggal Masuk :
    Raya Rengasdengklok - KM 2 Kec. Hari ke / Tanggal :
    Rengasdengklok Gol. Darah / RH

    INTENSIVE CARE CHART


    ICU JENIS

    Identitas Khusus
    Nama Pasien :……………………………………………..……..(L/P)
    Tgl Lahir :Tgl……….…..... bln………..….. Thn…………..
    No. Rekam medis : ……………..………………………………………….
    Identitas Klinis
    TB : ………………..…………………………………………
    BB : ………………..………………………………………….
    Alergi : ………………...…………………………………………

    07 08 09 10 11 12

    HR RR
    T 120 NIBP
    41 250
    200

    180 40 110 225

    160 39 100 200

    140 38 90 175

    120 37 80 150

    100 36 70 125
    100 36 70 125

    80 35 60 100

    60 34 50 75

    40 32 40 50

    20 31 30 25

    0 0 20 0

    MAP
    CVP
    Saturasi O2
    EKG Monitoring
    NEURO R L R L
    Pupil Size
    Pupil Reaction
    GCS : E/V/M

    RESPIRATORI
    07 08 09 10
    Tipe Ventilasi
    PEEP
    Resp. Rate
    Tidal Volum /M.V
    Fi O2
    P. Inspirasi
    Flow / I : E Ratio
    Pressure
    Size ETT/ Pressurecuff

    NURSING
    Position
    Eye Care
    Mouth Care
    Bed Bath / Perianal Care
    Wound Care
    Suction
    INTAKE 07 08 09 10
    Infus CA CM CA CM CA CM
    1
    2
    3
    4
    5
    6
    7
    8
    Laboratorium
    1
    2
    3
    4
    5
    6
    Medicine Drip / Pump
    1
    2
    3
    4
    5
    6
    Tranfusion
    1
    2
    3
    DIET
    Hourly Total
    Running Total
    TOTAL INTAKE / 24 JAM

    OUT PUT
    Drain

    NGT
    DEFECATION
    URIN
    Hourly Total
    RUNNING TOTAL
    IWL / 24 JAM
    TOTAL OUT PUT 24 JAM
    BALANCE
    COMMENTS

    PERAWAT (NAMA / IDENTITAS)


    Masuk : Dari :
    / Tanggal :
    ah / RH

    INVASIVE DEVICE

    JENIS UKURAN TGL PASANG

    10 11 12 13 14 15 16 17 18 19 20 21
    L R L R L R L R L

    10 11 12 13 14
    10 11 12 13 14
    CA CM CA CM CA CM CA CM
    Dokter yang merawat :

    Konsultan

    TANGGAL GANTI KETERANGAN

    20 21 22 23 24 01 02 03 04 05 06 07
    L R L R L R L R L

    14 15 16 17 18
    14 15 16 17 18
    CA CM CA CM CA CM CA CM
    L R L R L R L R L

    18 19 20 21 22
    18 19 20 21 22
    CA CM CA CM CA CM CA CM
    Diagnosis :

    Jenis dan Tanggal Operasi


    L R L R L R L R L

    22 23 24 01 02
    22 23 24 01 02
    CA CM CA CM CA CM CA CM
    HR

    X Temp

    RR

    BP
    L R L R L R L R L R L R L R

    02 03 04 05 06 07
    02 03 04 05 06 07 TOTAL
    CA CM CA CM CA CM CA CM CA CM
    Column1Column2 Column4 Column5 Column6

    TGL OBAT - OBATAN 07 08


    INTRUKSI DOKTER
    NAMA DOKTER
    PARAF

    Jam
    NSR : Normal Sinus Rhythm
    AF : Atrial Fibrillation
    AFL : Atria Flutter
    AES : Atria Extra Systole
    VF : Ventrikular Fibrilation
    SVES : Supra Ventrikular Extra Sistol
    VES : Ventrikular Extra Sistol
    PAT : Paroxysmal Atrial tachycardial
    JR : Junctional Rhytm - Nodal Rhytm
    VT : Ventricular Tachycardia
    Column7 Column8 Column9 Column1 Column1 Column1 Column1 Column1 Column15 Column16Column1

    09 10 11 12 13 14 15 16 17 18 19
    CATATAN TERINTEGRASI CATATAN TERINTEGRASI
    STAF
    PARAF

    Jam Jam
    Column1 Column1 Column2 Column2 Column22 Column23 Column2 Column2 Column2 Column2 Column2

    20 21 22 23 24 01 02 03 04 05 06
    N TERINTEGRASI CATATAN TERINTEGRASI
    STAF STAF
    PARAF

    Jam
    Column29

    07
    PARAF

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