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LOGO RS



TGL/BLN/THN



PENGESAHAN:



CONTOH Panduan Praktik Klinis KSM/SMF : ………………………………………………………… RS............................................ REVISI KE......



DIREKTUR RS TANDA TANGAN DAN NAMA



NAMA PENYAKI :…………………………………………………….ICD -10 :……………………..



1. Pengertian (Definisi)



…………………………………………………………………………………………………………………. .



2. Anamnesis



…………………………………………………………………………………………………………………. . …………………………………………………………………………………………………………………. . …………………………………………………………………………………………………………………. . …………………………………………………………………………………………………………………. . …………………………………………………………………………………………………………………. .



3. Pemeriksaan Fisik



…………………………………………………………………………………………………………………. . …………………………………………………………………………………………………………………. . …………………………………………………………………………………………………………………. . …………………………………………………………………………………………………………………. . …………………………………………………………………………………………………………………. . …………………………………………………………………………………………………………………. . …………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………



4. Kriteria Diagnosis



1. 2.



……………………………………………………………………………………………………. ……………………………………………………………………………………………………



3. 4. 5.



5. Diagnosis 6. Diagnosis Banding



…………………………………………………………………………………………………… ………………………………………………………………………………………………….. …………………………………………………………………………….........................



………………………………………………………………………………………………. 1. 2. 3.



…………………………………………………………………………………………………. …………………………………………………………………………………………………. …………………………………………………………………………………………………



7. Pemeriksaan Penunjang



1. 2. 3. 4. 5.



…………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… ……………………………………………………………………………........



8. Terapi



1. 2. 3. 4. 5.



…………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… ……………………………………………………………………………........



9. Edukasi



1. 2. 3. 4. 5.



…………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… ……………………………………………………………………………........



10. Prognosis 11. Tingkat Evidens 12. Tingkat Rekomendasi 13. Penelaah Kritis



14. Indikator Medis 15. Kepustakaan



Ad vitam : dubia ad bonam/malam Ad sanationam : dubia ad bonam/malam Ad fumgsionam : dubia ad bonam/malam I/II/III/IV A/B/C 1. 2. 3. 4.



…………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… ……………………………………………………………………………………



……………………………………………………………………………………………… …………………………………………………………………………………………….. …………………………………………………………………………………………….. 1. …………………………………………………………………………………… 2. …………………………………………………………………………………… 3. …………………………………………………………………………………… 4. …………………………………………………………………………………… 5. ……………………………………………………………………………........



Ketua Komite Medik ....................................



Penyusun : ......................................