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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 : ......................................