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File: pasien keluar ICU.html
<html> <head> <meta http-equiv="Content-Type" content="text/html; charset=UTF-8"> <style type="text/css"> .txt { white-space:nowrap; } #f0 { font-family:sans-serif; font-weight:normal; font-style:normal; } #f1 { font-family:sans-serif; font-weight:bold; font-style:normal; } #f2 { font-family:sans-serif; font-weight:normal; font-style:normal; } @font-face { font-family: ff0; src: url("0.ttf"); } #f3 { font-family:ff0,monospace; font-weight:normal; font-style:normal; } #f4 { font-family:sans-serif; font-weight:bold; font-style:italic; } @font-face { font-family: ff1; src: url("1.ttf"); } #f5 { font-family:ff1,sans-serif; font-weight:normal; font-style:normal; } #f6 { font-family:monospace; font-weight:normal; font-style:normal; } @font-face { font-family: ff2; src: url("2.ttf"); } #f7 { font-family:ff2,sans-serif; font-weight:normal; font-style:normal; } </style> </head> <body> <img id="background" style="position:absolute; left:0px; top:0px;" width="595" height="841" src="page1.png"> <div class="txt" style="position:absolute; left:261px; top:9px;"><span id="f1" style="font-size:9px;vertical-align:baseline;color:rgba(0,175,80,1);">RUMAH SAKIT</span></div> <div class="txt" style="position:absolute; left:281px; top:20px;"><span id="f1" style="font-size:9px;vertical-align:baseline;color:rgba(255,0,0,1);">AULIA</span></div> <div class="txt" style="position:absolute; left:262px; top:32px;"><span id="f2" style="font-size:9px;vertical-align:baseline;color:rgba(4,98,193,1);">www.rsaulia.com</span></div> <div class="txt" style="position:absolute; left:162px; top:43px;"><span id="f2" style="font-size:9px;vertical-align:baseline;color:rgba(0,0,0,1);">Alamat : Jalan Jeruk Raya No. 15, Jagakarsa, Jakarta Selatan 12620</span></div> <div class="txt" style="position:absolute; left:246px; top:55px;"><span id="f2" style="font-size:9px;vertical-align:baseline;color:rgba(0,0,0,1);">Email : info@rsaulia.com</span></div> <div class="txt" style="position:absolute; left:227px; top:66px;"><span id="f2" style="font-size:9px;vertical-align:baseline;color:rgba(0,0,0,1);">Telp : (021) 7270208; 7866057</span></div> <div class="txt" style="position:absolute; left:452px; top:17px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">No Form : FR.ICU.108-22</span></div> <div class="txt" style="position:absolute; left:453px; top:37px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">No Rev : 00</span></div> <div class="txt" style="position:absolute; left:143px; top:90px;"><span id="f1" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">FORMULIR PASIEN KELUAR </span><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">INTENSIVE CARE UNIT (ICU)</span></div> <div class="txt" style="position:absolute; left:60px; top:129px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Nama Pasien</span></div> <div class="txt" style="position:absolute; left:60px; top:141px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Tgl. Lahir/ Jenis Kelamin</span></div> <div class="txt" style="position:absolute; left:60px; top:154px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">No. RM</span></div> <div class="txt" style="position:absolute; left:60px; top:167px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Alamat</span></div> <div class="txt" style="position:absolute; left:32px; top:180px;"><span id="f1" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Diagnosa Medis :</span></div> <div class="txt" style="position:absolute; left:245px; top:116px;"><span id="f1" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">IDENTITAS PASIEN</span></div> <div class="txt" style="position:absolute; left:184px; top:129px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">: ........................................................ Ruang : .........................</span></div> <div class="txt" style="position:absolute; left:184px; top:141px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">: ........................................................</span></div> <div class="txt" style="position:absolute; left:184px; top:154px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">: ........................................................</span></div> <div class="txt" style="position:absolute; left:184px; top:167px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">: ........................................................</span></div> <div class="txt" style="position:absolute; left:32px; top:206px;"><span id="f1" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">KESADARAN</span></div> <div class="txt" style="position:absolute; left:32px; top:219px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">GCS >8</span></div> <div class="txt" style="position:absolute; left:32px; top:232px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Kejang terkontrol</span></div> <div class="txt" style="position:absolute; left:32px; top:271px;"><span id="f1" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">JALAN NAPAS</span></div> <div class="txt" style="position:absolute; left:34px; top:284px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Jalan napas paten</span></div> <div class="txt" style="position:absolute; left:216px; top:206px;"><span id="f1" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">PERNAPASAN</span></div> <div class="txt" style="position:absolute; left:216px; top:219px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Tidak memerlukan ventilasi</span></div> <div class="txt" style="position:absolute; left:229px; top:232px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">mekanik</span></div> <div class="txt" style="position:absolute; left:216px; top:245px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">SpO2 >92 % dengan NRM </span><span id="f7" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">≥ </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">6</span></div> <div class="txt" style="position:absolute; left:229px; top:258px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Lpm</span></div> <div class="txt" style="position:absolute; left:216px; top:271px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Tidal Volume >5 ml/kgbb</span></div> <div class="txt" style="position:absolute; left:216px; top:285px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">PaO2 >60 mmHg</span></div> <div class="txt" style="position:absolute; left:216px; top:298px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">PaCO2 <50 mmHg</span></div> <div class="txt" style="position:absolute; left:216px; top:311px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">PaO2 / FiO2 >200</span></div> <div class="txt" style="position:absolute; left:398px; top:206px;"><span id="f1" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">SIRKULASI</span></div> <div class="txt" style="position:absolute; left:398px; top:219px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Hr <90 atau >50 x/menit dengan</span></div> <div class="txt" style="position:absolute; left:409px; top:232px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">pulsasi kuat.</span></div> <div class="txt" style="position:absolute; left:398px; top:245px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">MAP >65 mmHg atau <150</span></div> <div class="txt" style="position:absolute; left:409px; top:258px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">mmHG</span></div> <div class="txt" style="position:absolute; left:398px; top:271px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Produksi urine >0,5 ml/kgBB/jam</span></div> <div class="txt" style="position:absolute; left:398px; top:285px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Tidak memerlukan obat vasoaktif</span></div> <div class="txt" style="position:absolute; left:409px; top:297px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">/ anti aritmia kontinyu.</span></div> <div class="txt" style="position:absolute; left:32px; top:336px;"><span id="f1" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">KONDISI LAIN :</span></div> <div class="txt" style="position:absolute; left:34px; top:349px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Tidak lagi membutuhkan Continuos Renal Replacement Therapy</span></div> <div class="txt" style="position:absolute; left:34px; top:363px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Tidak lagi memerlukan titrasi insulin</span></div> <div class="txt" style="position:absolute; left:34px; top:376px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Pasien meninggal / dinyatakan mati batang otak, dalam vegetatif permanen</span></div> <div class="txt" style="position:absolute; left:34px; top:389px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Menolak intervensi aktif, terapi bantuan hidup (menandatangani form penolakan tindakan)</span></div> <div class="txt" style="position:absolute; left:34px; top:403px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Pasien / keluarga menghendaki dirawat diluar ruang rawat intensif.</span></div> <div class="txt" style="position:absolute; left:34px; top:416px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Lainnya</span></div> <div class="txt" style="position:absolute; left:48px; top:429px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">...........................................................................................................................................................................................</span></div> <div class="txt" style="position:absolute; left:32px; top:468px;"><span id="f1" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Keterangan :</span></div> <div class="txt" style="position:absolute; left:32px; top:620px;"><span id="f1" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Kesimpulan :</span></div> <div class="txt" style="position:absolute; left:32px; top:632px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Pasien dapat dipindahkan dari ICU</span></div> <div class="txt" style="position:absolute; left:32px; top:645px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Dipindah ke ruang .................................................................................</span></div> <div class="txt" style="position:absolute; left:209px; top:671px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Jakarta, ..................................... Jam ...........</span></div> <div class="txt" style="position:absolute; left:235px; top:685px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Dokter Penanggung Jawab ICU</span></div> <div class="txt" style="position:absolute; left:230px; top:731px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">.......................................................</span></div> <div class="txt" style="position:absolute; left:235px; top:745px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Nama Terang dan Tanda tangan</span></div> </body> </html>