Form Cp Mata

8/12/2019 Form Cp Mata

1/14

FORMAT UMUM CLINICAL PATHWAYS

11

CLINICAL PATHWAYSCLINICAL PATHWAYS

SMF MATA .SMF MATA .22RSUD Dr. PIRNGADI KOTA MEDANRSUD Dr. PIRNGADI KOTA MEDAN 33

KATARAK KONGENITALKATARAK KONGENITAL 44

20132013 55

Nama Pa!"# $ ....................Nama Pa!"# $ ....................

%%

Um&r $ ............Um&r $ .............. ''

("ra)("ra)(a*a# $ .......... +,(a*a# $ .......... +, --

T!#,,!T!#,,!(a*a# $ ........(a*a# $ ........

mm //

Nmr R"+am M"*!$Nmr R"+am M"*!$

1010

Diagnosis : .KATARAKDiagnosis : .KATARAK

KONGENITAL...........KONGENITAL........... 1111K*" ICD 10 $ ......K*" ICD 10 $ ......1212 R"#a#a raa) $3' HARI ar! 13R"#a#a raa) $3' HARI ar! 13

Aktivitas PelayananAktivitas PelayananR.R.

Raa) .......Raa) .......1414

T,6amT,6am

ma&+$ ........ma&+$ ........ 1515T,6amT,6am

+"&ar$ ........+"&ar$ ........ 1%1%LamaLama

R)$ ........R)$ ........ 1'1'K"a $ ...K"a $ ...

.......... 1-1-Tar!7rTar!7r

8R9: $ ........8R9: $ ........ 1/1/(!a;a(!a;a

8R9: .....................8R9: .....................

.. 2020

..........................

.

Har! Raa) 1Har! Raa) 1 Har! Raa) 2Har! Raa) 2 Har! Raa) 3Har! Raa) 3 Har! Raa) 4Har! Raa) 4 Har! Raa) 5Har! Raa) 5

Har! Sa+!) $ ...Har! Sa+!) $ ... Har! Sa+!) $ ...Har! Sa+!) $ ... Har! Sa+!) $ ...Har! Sa+!) $ ... Har! Sa+!) $ ...Har! Sa+!) $ ... Har! Sa+!) $ ...Har! Sa+!) $ ...

D!a,#! $ Ka)ara+ K#,"#!)aD!a,#! $ Ka)ara+ K#,"#!)a

PenyakitPenyakit UUtamatama 2222 ............................................................................

..............

............................................ ............................................ ............................................

Penyakit PenyertaPenyakit Penyerta 22 ........................................................................ ............................................ ............................................ ............................................

Kom!likasiKom!likasi 2"2" ................................................

........................

..................

............................................ ............................................ ............................................

A"m"# K!#! $A"m"# K!#! $

Pemeriksaan #okterPemeriksaan #okter

$lit Lam!$lit Lam!

%&n#&sko!i%&n#&sko!i

TonometriTonometri 2'2'

(onitori:(onitori:................................

..........

............................................ ............................................ ............................................ ............................................

Kons&ltasiKons&ltasi

Interna)Pe#iatriInterna)Pe#iatri 2*2* ................................

..........

............................................ ............................................ ............................................ ............................................

Pemeriksaan + La, Pen&n-angPemeriksaan + La, Pen&n-ang

iometriiometri

/$G 0KIP/$G 0KIP22................................

..

............................................ ............................................ ............................................ ............................................

Tin#akan : Ekstrasi KatarakTin#akan : Ekstrasi Katarak

Ekstra Ka!s&lar #enganEkstra Ka!s&lar #engan

im!lantasi Lensa Tanamim!lantasi Lensa Tanam

OD)O$OD)O$

......................................................................................

..........

............................................ ............................................ ............................................ ............................................

O,at3o,atan :O,at3o,atan : 22 IOL : 1IOL : 1

In4&s $et : 1In4&s $et : 1

Ringer Laktat : 1 4l5Ringer Laktat : 1 4l5

Li#okain 26 : 1 4l5Li#okain 26 : 1 4l5

Gentamisin in- : 7 4l5Gentamisin in- : 7 4l5

De8a in- : 7 4l5De8a in- : 7 4l5

$!&it 1 55 : $!&it 1 55 :

$!&it 19 55 : 2$!&it 19 55 : 2

(etilen ,l&e : 7 4l5(etilen ,l&e : 7 4l5

(iostat : 7 4l5(iostat : 7 4l5

;ealon : 7 4l5;ealon : 7 4l5

Etilon 19)9 : 7 ,ksEtilon 19)9 : 7 ,ks arians :>arians : ............................................ .......................................... ............................................ ............................................ ............................................

Nama Pera?at : .................Nama Pera?at : .................**

Diagnosis AkirDiagnosis Akir "" Ko#e I


2/14

.......................................... ............................................


11



KATARAK MATUR ODOSKATARAK MATUR ODOS 44

20132013 55

Nama Pa!"# $ ....................Nama Pa!"# $ .................... %% Um&r $ ............Um&r $ ............

.. ''("ra)("ra)

(a*a# $ .......... +,(a*a# $ .......... +, --T!#,,!T!#,,!

(a*a# $ ........(a*a# $ ........

mm //

Nmr R"+am M"*!$Nmr R"+am M"*!$ 1010

Diagnosis : .KATARAK (at&r OD)O$Diagnosis : .KATARAK (at&r OD)O$1111 K*" ICD 10 $ ......K*" ICD 10 $ ......1212 R"#a#a raa) $3' HARI ar! 13R"#a#a raa) $3' HARI ar! 13


Raa) .......Raa) .......1414

T,6amT,6am

ma&+$ ........ma&+$ ........ 1515T,6amT,6am

+"&ar$ ........+"&ar$ ........ 1%1%LamaLama

R)$ ........R)$ ........ 1'1'K"a $ ...K"a $ ...

.......... 1-1-Tar!7rTar!7r

8R9: $ ........8R9: $ ........ 1/1/(!a;a(!a;a

8R9: .....................8R9: .....................

.. 2020

..........................

.



D!a,#! $ Ka)ara+ Ma)&r ODOSD!a,#! $ Ka)ara+ Ma)&r ODOS

PenyakitPenyakit UUtamatama 2222 ....................................................

......................................

............................................ ............................................ ............................................

Penyakit PenyertaPenyakit Penyerta 22 ................................................

........................ ............................................ ............................................ ............................................

Kom!likasiKom!likasi 2"2" ................................................

........................

..................

............................................ ............................................ ............................................

A"m"# K!#! $A"m"# K!#! $


$lit Lam!$lit Lam!



(onitori:(onitori:................................

..........

............................................ ............................................ ............................................ ............................................


Interna)Pe#iatriInterna)Pe#iatri 2*2*................................

..........

............................................ ............................................ ............................................ ............................................


iometriiometri/$G 0KIP/$G 0KIP22

..................................

............................................ ............................................ ............................................ ............................................

Tin#akan : Ekstrasi KatarakTin#akan : Ekstrasi Katarak

Ekstra Ka!s&lar #enganEkstra Ka!s&lar #engan

im!lantasi Lensa Tanamim!lantasi Lensa Tanam

OD)O$OD)O$

......................................................................................

..........

............................................ ............................................ ............................................ ............................................

O,at3o,atan :O,at3o,atan : 22 IOL : 1IOL : 1

In4&s $et : 1In4&s $et : 1

Ringer Laktat : 1 4l5Ringer Laktat : 1 4l5

Li#okain 26 : 1 4l5Li#okain 26 : 1 4l5

Gentamisin in- : 7 4l5Gentamisin in- : 7 4l5

De8a in- : 7 4l5De8a in- : 7 4l5

$!&it 1 55 : $!&it 1 55 :

$!&it 19 55 : 2$!&it 19 55 : 2

(etilen ,l&e : 7 4l5(etilen ,l&e : 7 4l5

(iostat : 7 4l5(iostat : 7 4l5

;ealon : 7 4l5;ealon : 7 4l5

Etilon 19)9 : 7 ,ksEtilon 19)9 : 7 ,ks

arians :>arians : ............................................ .......................................... ............................................ ............................................ ............................................


Diagnosis Akir Pseo!akia OD)O$Diagnosis Akir Pseo!akia OD)O$""

Ko#e I


3/14

Nama Pelaksana >eri4ikasi :Nama Pelaksana >eri4ikasi :

.................................. Kom!likasiKom!likasi .......................................... ............................................

.......................................... ............................................


11



ENDOPTHALMITIS ODOS < TRAUMA OCULI (ERAT < PROLAPSENDOPTHALMITIS ODOS < TRAUMA OCULI (ERAT < PROLAPS

IRIS


4/14


11

CLINICAL PATHWAYSCLINICAL PATHWAYSSMF MATA .SMF MATA .22RSUD Dr. PIRNGADI KOTA MEDANRSUD Dr. PIRNGADI KOTA MEDAN 33

RETINO(LASTOMARETINO(LASTOMA 44

20132013 55


.. ''("ra)("ra)

(a*a# $ .......... +,(a*a# $ .......... +, --T!#,,!T!#,,!

(a*a# $ ........(a*a# $ ........

mm //


Diagnosis : .RETINOLA$TO(A..........Diagnosis : .RETINOLA$TO(A.......... 1111 K*" ICD 10 $ ......K*" ICD 10 $ ......1212 R"#a#a raa) $% 8ENAM: HARI 13R"#a#a raa) $% 8ENAM: HARI 13


Raa) .......Raa) .......1414

T,6amT,6am

ma&+$ ........ma&+$ ........ 1515T,6amT,6am

+"&ar$ ........+"&ar$ ........ 1%1%LamaLama

R)$ ........R)$ ........ 1'1'K"a $ ...K"a $ ...

.......... 1-1-Tar!7rTar!7r

8R9: $ ........8R9: $ ........ 1/1/(!a;a(!a;a

8R9: .....................8R9: .....................

.. 2020

..........................

.



D!a,#! $ RETINO(LASTOMAD!a,#! $ RETINO(LASTOMA

PenyakitPenyakit UUtamatama 2222 ....................................................

........................

..............

............................................ ............................................ ............................................


Kom!likasiKom!likasi 2"2" ........................................................................

..................

............................................ ............................................ ............................................

A"m"# K!#! $A"m"# K!#! $


$lit Lam!$lit Lam!

%&n#&sko!i%&n#&sko!i TonometriTonometri 2'2'

(onitori:(onitori:................................

..........

............................................ ............................................ ............................................ ............................................


Interna)Pe#iatriInterna)Pe#iatri 2*2*................................

..........

............................................ ............................................ ............................................ ............................................


iometriiometri

/$G 0KIP/$G 0KIP22................................

..

............................................ ............................................ ............................................ ............................................

Tin#akan : EN/KLEA$ITin#akan : EN/KLEA$I

OD)O$OD)O$......................................................

................................

..........

............................................ ............................................ ............................................ ............................................

O,at3o,atan :O,at3o,atan : 22 y5ril *)9 : 1


5/14


11



TUMOR INTRA OKULITUMOR INTRA OKULI44

20132013 55


.. ''("ra)("ra)

(a*a# $ .......... +,(a*a# $ .......... +, --T!#,,!T!#,,!

(a*a# $ ........(a*a# $ ........

mm //


Diagnosis : .T/(OR INTRA OK/LI...........Diagnosis : .T/(OR INTRA OK/LI........... 1111 K*" ICD 10 $ ......K*" ICD 10 $ ......1212 R"#a#a raa) $3' HARI ar! 13R"#a#a raa) $3' HARI ar! 13


Raa) .......Raa) .......1414

T,6amT,6am

ma&+$ ........ma&+$ ........ 1515T,6amT,6am

+"&ar$ ........+"&ar$ ........ 1%1%LamaLama

R)$ ........R)$ ........ 1'1'K"a $ ...K"a $ ...

.......... 1-1-Tar!7rTar!7r

8R9: $ ........8R9: $ ........ 1/1/(!a;a(!a;a

8R9: .....................8R9: .....................

.. 2020

..........................

.


Har! Sa+!) $ ...Har! Sa+!) $ ...

Har! Sa+!) $ ...Har! Sa+!) $ ...

Har! Sa+!) $ ...Har! Sa+!) $ ...

Har! Sa+!) $ ...Har! Sa+!) $ ...

Har! Sa+!) $ ...Har! Sa+!) $ ...

D!a,#! $ T&mr I#)ra O+&!D!a,#! $ T&mr I#)ra O+&!


..............

............................................ ............................................ ............................................



..................

............................................ ............................................ ............................................

A"m"# K!#! $A"m"# K!#! $


$lit Lam!$lit Lam!



(onitori:(onitori:................................

..........

............................................ ............................................ ............................................ ............................................


Interna)Pe#iatriInterna)Pe#iatri 2*2* ..........................................

............................................ ............................................ ............................................ ............................................


iometriiometri

/$G 0KIP/$G 0KIP22................................

..

............................................ ............................................ ............................................ ............................................

Tin#akan :Tin#akan : ......................................................................................

..........

............................................ ............................................ ............................................ ............................................

O,at3o,atan :O,at3o,atan : 22

y5ril *)9 : 1


6/14


11



TUMOR GANAS EKSTRA OKULI ODOSTUMOR GANAS EKSTRA OKULI ODOS 44

20132013 55


.. ''("ra)("ra)

(a*a# $ .......... +,(a*a# $ .......... +, --T!#,,!T!#,,!

(a*a# $ ........(a*a# $ ........

mm //


Diagnosis : T/(OR GANA$ EK$TRADiagnosis : T/(OR GANA$ EK$TRA

OK/LI OD)O$..........OK/LI OD)O$.......... 1111K*" ICD 10 $ ......K*" ICD 10 $ ......1212 R"#a#a raa) $3' HARI ar! 13R"#a#a raa) $3' HARI ar! 13

Aktivitas PelayananAktivitas Pelayanan R.R.Raa) .......Raa) .......

1414

T,6amT,6amma&+$ ........ma&+$ ........ 1515

T,6amT,6am+"&ar$ ........+"&ar$ ........ 1%1%

LamaLamaR)$ ........R)$ ........ 1'1'

K"a $ ...K"a $ ............. 1-1-

Tar!7rTar!7r8R9: $ ........8R9: $ ........ 1/1/

(!a;a(!a;a

8R9: .....................8R9: .....................

.. 2020

..........................

.



D!a,#! $ T&mr Ga#a E+)ra O+&! ODOSD!a,#! $ T&mr Ga#a E+)ra O+&! ODOS


..............

............................................ ............................................ ............................................



..................

............................................ ............................................ ............................................

A"m"# K!#! $A"m"# K!#! $


$lit Lam!$lit Lam!



(onitori:(onitori:................................

..........

............................................ ............................................ ............................................ ............................................


Interna)Pe#iatriInterna)Pe#iatri 2*2* ................................

..........

............................................ ............................................ ............................................ ............................................


iometriiometri

/$G 0KIP/$G 0KIP22................................

..

............................................ ............................................ ............................................ ............................................

Tin#akan :Tin#akan : ......................................................................................

..........

............................................ ............................................ ............................................ ............................................



7/14

.......................................... ............................................


11



PTRYGIUM ODOSPTRYGIUM ODOS 44

20132013 55


.. ''("ra)("ra)

(a*a# $ .......... +,(a*a# $ .......... +, --T!#,,!T!#,,!

(a*a# $ ........(a*a# $ ........

mm //


Diagnosis : PTRGI/( OD)O$..........Diagnosis : PTRGI/( OD)O$.......... 1111 K*" ICD 10 $ ......K*" ICD 10 $ ......1212 R"#a#a raa) $ 13R"#a#a raa) $ 13


Raa) .......Raa) .......1414

T,6amT,6am

ma&+$ ........ma&+$ ........1515

T,6amT,6am

+"&ar$ ........+"&ar$ ........1%1%

LamaLama

R)$ ........R)$ ........1'1'

K"a $ ...K"a $ ...

..........1-1-

Tar!7rTar!7r

8R9: $ ........8R9: $ ........1/1/ (!a;a(!a;a

8R9: .....................8R9: .....................

.. 2020

..........................

.



D!a,#! $ PTRYGIUMD!a,#! $ PTRYGIUM


..............

............................................ ............................................ ............................................



..................

............................................ ............................................ ............................................

A"m"# K!#! $A"m"# K!#! $

Pemeriksaan #okterPemeriksaan #okter $lit Lam!$lit Lam! 2'2'

(onitori:(onitori:

................................

..........

............................................ ............................................ ............................................ ............................................

Kons&ltasiKons&ltasi2*2* ................................

..........

............................................ ............................................ ............................................ ............................................

Pemeriksaan + La, Pen&n-angPemeriksaan + La, Pen&n-ang22 ................................

..

............................................ ............................................ ............................................ ............................................

Tin#akan :Tin#akan : ......................................................................................

..........

............................................ ............................................ ............................................ ............................................



8/14


11


SOCKET SYNDROME ODOSSOCKET SYNDROME ODOS 44

20132013 55


.. ''("ra)("ra)

(a*a# $ .......... +,(a*a# $ .......... +, --T!#,,!T!#,,!

(a*a# $ ........(a*a# $ ........

mm //


Diagnosis : $O


9/14


11


LASERAN PALPE(RA < KERUSAKAN (ERAT PALPE(RA ODOSLASERAN PALPE(RA < KERUSAKAN (ERAT PALPE(RA ODOS 44

20132013 55


.. ''("ra)("ra)

(a*a# $ .......... +,(a*a# $ .......... +, --T!#,,!T!#,,!

(a*a# $ ........(a*a# $ ........

mm //


Diagnosis : LA$ERAN PALPERA +Diagnosis : LA$ERAN PALPERA +

KER/$AKAN ERAT PALPERA OD)O$ ....KER/$AKAN ERAT PALPERA OD)O$ ....1111

K*" ICD 10 $ ......K*" ICD 10 $ ......1212 R"#a#a raa)$ ar! 13R"#a#a raa)$ ar! 13


Raa) .......Raa) .......1414

T,6amT,6am

ma&+$ ........ma&+$ ........ 1515T,6amT,6am

+"&ar$ ........+"&ar$ ........ 1%1%LamaLama

R)$ ........R)$ ........ 1'1'K"a $ ...K"a $ ...

.......... 1-1-Tar!7rTar!7r

8R9: $ ........8R9: $ ........ 1/1/(!a;a(!a;a

8R9: .....................8R9: ....................... 2020

..........................

.



D!a,#! $ La"ra# Pa9"=ra < K"r&a+a# ("ra) Pa9"=ra ODOSD!a,#! $ La"ra# Pa9"=ra < K"r&a+a# ("ra) Pa9"=ra ODOS


..............

............................................ ............................................ ............................................



..................

............................................ ............................................ ............................................

A"m"# K!#! $A"m"# K!#! $


$lit Lam!$lit Lam!2'2'(onitori:(onitori:

..........................................

............................................ ............................................ ............................................ ............................................

Kons&ltasiKons&ltasi 2*2*................................

..........

............................................ ............................................ ............................................ ............................................

Pemeriksaan + La, Pen&n-angPemeriksaan + La, Pen&n-ang22 ................................

..

............................................ ............................................ ............................................ ............................................

Tin#akan :Tin#akan : ......................................................................................

..........

............................................ ............................................ ............................................ ............................................



10/14


11


GLAUCOMA ODOSGLAUCOMA ODOS 44

20132013 55


.. ''("ra)("ra)

(a*a# $ .......... +,(a*a# $ .......... +, --T!#,,!T!#,,!

(a*a# $ ........(a*a# $ ........

mm //


Diagnosis : GLA/


11/14

Nama Dokter : .................Nama Dokter : .................

PenyertaPenyerta .......................................... ............................................

.......................................... ............................................

Nama Pelaksana >eri4ikasi :Nama Pelaksana >eri4ikasi :


.......................................... ............................................


11



GLAUCOMA DENGAN KATARAK ODOSGLAUCOMA DENGAN KATARAK ODOS 44

20132013 55


.. ''("ra)("ra)

(a*a# $ .......... +,(a*a# $ .......... +, --T!#,,!T!#,,!

(a*a# $ ........(a*a# $ ........

mm//


Diagnosis : GLA/


12/14


Diagnosis AkirDiagnosis Akir "" Ko#e Ieri4ikasi :


.......................................... ............................................


11



CHALA>IONHORDEOLUMGRANULOMACHALA>IONHORDEOLUMGRANULOMA 44

20132013 55


.. ''("ra)("ra)

(a*a# $ .......... +,(a*a# $ .......... +, --T!#,,!T!#,,!

(a*a# $ ........(a*a# $ ........

mm //


Diagnosis :


13/14


11



ULKUS CORNEAULKUS CORNEA 44

20132013 55

Nama Pa!"# $ ....................Nama Pa!"# $ .................... %% Um&r $ ......Um&r $ ......

.............. ''("ra)("ra)

(a*a# $ ..........(a*a# $ ..........

+,+, --

T!#,,! (a*a# $T!#,,! (a*a# $

........ m........ m //Nmr R"+am M"*!$Nmr R"+am M"*!$

1010

Diagnosis : /L


14/14

NamaNama

Pera?at : .................Pera?at : .................**

Diagnosis AkirDiagnosis Akir "" Ko#e I

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