Scribd
Upload
40 views2 pages

Catatan Perkembangan Pasien Terintegrasi

This document is a template for recording a patient's integrated treatment progress notes. It includes sections for the date and time, examining doctor's notes using the SOAP/ADIME format, instructions for healthcare workers, and spaces for signatures and stamps from doctors and nurses to verify plans and instructions. The goal is to document examination results, analysis, treatment plans, post-surgery/procedure instructions clearly and measurably with the aim of integrated and verified care.

Uploaded by

siska
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
40 views2 pages

Catatan Perkembangan Pasien Terintegrasi

This document is a template for recording a patient's integrated treatment progress notes. It includes sections for the date and time, examining doctor's notes using the SOAP/ADIME format, instructions for healthcare workers, and spaces for signatures and stamps from doctors and nurses to verify plans and instructions. The goal is to document examination results, analysis, treatment plans, post-surgery/procedure instructions clearly and measurably with the aim of integrated and verified care.

Uploaded by

siska
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

RM.

04
CATATAN PERKEMBANGAN No.Rekam Medis :
Nama :
PASIEN TERINTEGRASI Tgl Lahir/ Umur : L/P
R Ruang Rawat/ Poliklinik : ................................................

Verikasi DPJP
(Bubuhkan
INSTRUKSI TENAGA Stempel Nama,
HASIL PEMERIKSAAN, ANALISIS, RENCANA PENATALAKSANAAN PASIEN KESEHATAN TERMASUK Paraf, Tanggal
TANGGAL/ PASCA BEDAH/ PROSEDUR Dan Jam)
DOKTER
JAM (Ditulis dengan Format SOAP/ADIME, disertai dengan target yang terukur,
evaluasi hasil tatalaksana dituliskan dalam assesmen, harap bubuhkan (Instruksi ditulis dengan rinci (DPJP harus
stempel nama dan paraf setiap akhir catatan) dan jelas) membaca seluruh
rencana
perawatan)

Terima kasih atas kerjasamanya telah mengisi formulir ini dengan benar dan jelas

Revisi Tahun 2013


RM. 04
No.Rekam Medis :

Verikasi DPJP
(Bubuhkan
INSTRUKSI TENAGA Stempel Nama,
HASIL PEMERIKSAAN, ANALISIS, RENCANA PENATALAKSANAAN PASIEN KESEHATAN TERMASUK Paraf, Tanggal
PASCA BEDAH/ PROSEDUR Dan Jam)
TANGGAL/ DOKTER
(Ditulis dengan Format SOAP/ADIME, disertai dengan target yang terukur,
JAM (Instruksi ditulis dengan rinci (DPJP harus
evaluasi hasil tatalaksana dituliskan dalam assesmen, harap bubuhkan
stempel nama dan paraf setiap akhir catatan) dan jelas) membaca seluruh
rencana
perawatan)

Terima kasih atas kerjasamanya telah mengisi formulir ini dengan benar dan jelas

Revisi Tahun 2013

You might also like