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RM HD 160518 REV.

RSD Idaman Kota Banjarbaru NO. RM :


Jl. Trikora No.115 Guntung Manggis NAMA :
Banjarbaru Telp: 0511-6549696 TGL LAHIR :
Fax: 0511-6749697 JENIS KELAMIN :

ASUHAN MEDIS PASIEN HEMODIALISIS

Tanggal - - Jam : ........................................WIB

Asal Pasien Rawat Jalan Rawat Inap Rawat Darurat


I. Cara Bayar
BPJS BPI BPJS NO PBI Umum Kontraktor Lain-lain ................
II. Diagnosis Penyakit Ginjal
Etiologi :
Penyulit :
Penyakit Penyerta :
III. Anamnesis
:
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Anamnesis Ulang*)
...........................................................................................................................................................
IV. Pemeriksaan Fisik :
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Pengkajian Fisik Ulang*)
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V. Data Penunjang :
6. Posforanorganik
1. HBs-Ag 12. Kreatinin 7. Sat. Transferin
2. Ureum 13. Kalium
3. Natrium
8. Hemoglobin
14. TBC 9. Kalium
4. Fe Serum
15. Anti HIV 10. Gula Darah
5. Anti HCV
16. Asam Urat 11. ........................................................................
VI. Target Pengobatan : HD Akut HD Pre-Operasi SLEED ...................................

HD Rutin ..........kali/Minggu

- Frekwensi HD ..............................................................................................................................
- Pencapaian Adekuasi Dialisis ......................................................................................................
- Lainnya ........................................................................................................................................
VII. Resep Dialisis
1. Jenis Dialisat Bikarbonat
2. Akses Sirkulasi Femoral Cinimo Double Lumen Catheter Subelavia Jugular
3. Durasi hd (Td) : ..................... Jam
4. UF Goal : ..................... Mililiter
5. BB Kering : ..................... Kilogram
6. Kecepatan Aliran Darah : ..................... Mililiter per menit
7. Kecepatan Aliran Dialisat ......................Mililiter per menit
:
8. Heparinisasi Kontinue ......................U/jam LMWH
Intermiten
: ......................U/jam Tanpa Heparin
9. Program Profiling UF ............. Na ............... Bicarbonat ........................
10. Suhu ..................°C
VIII. Terapi
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Perubahan Terapi (diisi jika perubahan kurang dari 6 bulan) :
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Dokter Penanggung Jawab Pelayanan

(...........................................................)
Tanda tangan dan nama jelas

Catatan : 1. *)Coret yang tidak perlu 2. Beri tanda √ pada sesuai dengan pilihan