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