SKP.docx

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JessiLaurentius

akreditasi

Santé & Médecine

Natalia Anwar, Amd.Kep - INPATIENT (Bernadeth II)
bell dpjp
s: lapor pbm dengan diagnosa kolelitiasis
b: pasien mengatakan nyeri perut
a: ku lemah
kesadaran compos mentis
td: 103/81mmhg
s: 36
p:20x/mnt
n: 80x/mnt
skala nyeri sedang
lab terlampir
thoraks
usg abdoment tidak ada
r: mohon instruksi selanjutnya
rencana operasi besok jam 08:00 tanggal 22-12-2022 laparaskopi chole
lapor ok acc asni
pre op ambacin 1gr/skin test
puasa
konsul anastesi
dm lanjutkan instruksi

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SKP.docx

1. Natalia Anwar, Amd.Kep - INPATIENT (Bernadeth II) bell dpjp s: lapor pbm dengan diagnosa kolelitiasis b: pasien mengatakan nyeri perut a: ku lemah kesadaran compos mentis td: 103/81mmhg s: 36 p:20x/mnt n: 80x/mnt skala nyeri sedang lab terlampir thoraks usg abdoment tidak ada r: mohon instruksi selanjutnya rencana operasi besok jam 08:00 tanggal 22-12-2022 laparaskopi chole lapor ok acc asni pre op ambacin 1gr/skin test puasa konsul anastesi dm lanjutkan instruksi