chief report ob out 1 mei 2015.doc

IV. OBSTETRICS OUTPATIENT REPORTThursday, April 23rd, 2015 until Wednesday April 29th, 2015

Obstetric outpatient chief :1. dr. Rodiani : patients2. dr. Hendra Sugama Saputra : patients TOTAL : patients

DATE Total procedureUS examination MOW Suture removal Implant

insertionIUD

insertionApril 23rd 1 2 5April 24th 3 3 3April 25th 3 0 2 2April 26th HolidayApril 27th 7 0 8April 28th 3 0 1 5April 29th 0 1 TOTAL TOTAL

DATE VISITE PATIENTObstetric Lactation &

puerperalFamily

PlanningObstetric Lactation &

puerperalFamily

PlanningApril 23rd 1 4 7 1 4 7April 24th 3 1 6 3 1 6April 25th 3 0 10 3 0 10April 26th HolidayApril 27th 7 1 9 7 1 9April 28th 3 0 7 3 0 7April 29th 1 1 TOTAL

1. dr. RodianiOBSTETRIC CASENo Initial Age Add Diagnosis ICD Code Treatment/Plan Physician1 DIA 24 UA

US

G2P1A0 37 weeks gestational age not inlabor with prior CS 1x (o.i transverse lie) SLF transverse lie

38 weeks gestational age SLF cephalic presentation with suspicion of IUGR

Z.34N.21

- 1x400µg - Recontrolled

within 1 week- Informed consent

FCH-ROD

2 CAT 24 UA G2P1A0 9 weeks gestational age with ureterolithiasis SLF Intra uterine

Z.34N.21

- 1x400µg - Recontrolled

within 2 week- Informed consent

RZM-ROD

1

US8 weeks gestational age SLF intrauterine

LACTATION AND PUERPURALNo. Initial Age Add Diagnosis ICD Code Treatment/Plan Physician

1. EVI 31 UA P2A0 post LSCS due to macrosemia day 13rd

082.1 Roborantia BOY-SUG

2 NIG 23 UA P2A0 post spontaneous Delivery day 10th

082.1 Roborantia BOY-SUG

FAMILY PLANNING

No. Initial AgeStatus

(New/Old)/DateDiagnosis Contraception Physician

1 YUS 29 March 30th 2015 P2A0 post spontaneous bracht delivery (day 2)

O75.82

IUDZ97.5

BOY-SUG

2 LIS 31 March 31st 2015 P3A0 post spontaneous delivery (outside) + post

Brandt Andrew maneuver due to placental retention

(day 2) O75.82

IUDZ97.5

BOY-ROD

3 MAR 33 March 31st 2015 P3A0 post spontaneous delivery (outside) + post manual plasentae due to

placental retention (day 2) O75.82

IUDZ97.5

BOY-ROD

4 NET 26 March 31st 2015 P1A0 post spontaneous delivery (day 2)

O75.82

IUDZ97.5

BOY-ROD

5 PAS 41 March 31st 2015 P5A0 post spontaneous delivery with severe

preeclamsia + partial HELLP Syndrome (day 4)

O75.82O14.13O14.22

IUDZ97.5

BOY-ROD

NOASSESMENTdr. Rodiani

VALUE MAX Notes

1 Report technique 302 Paper acknowledgment 353 Honesty 35

Mean 100

2

2 dr. Hendra SugamaOBSTETRIC CASENo. Initial Age Add Diagnosis ICD Code Treatment/Plan Physician1 MIN 35 UA

US

G2P1A0 25 weeks gestational age SLF Intra uterine with suspicion of right solid ovarian neoplasm

22 weeks gestational age SLF intra uterine + subserous uterine myoma

Z.34Xxx

- 1x400µg - Recontrolled within 2

week

FCH-SUG

2 MET 18 UA

US

G1P0A0 29 weeks gestational Twin Life Fetus breech presentation – transvere lie

29 weeks Twin Life Fetus breech presentation-transvere lie

Z.34 - 1x400µg - Recontrolled within 2

week- Informed concern

EDP-ROD

LACTATION AND PUERPERALNo. Initial Age Add Diagnosis ICD Code Treatment/Plan Physician

1 SUN 32 UA

P4A0 post LSCS due to placentae previa totalis with active bleeding +

pomeroy tubectomy day 10th

082.1 Roborantia ROB-SUG

FAMILY PLANNING


(New/Old)/DateDiagnosis Contraception

Physician

1 TEN 23 March 26th 2015 P2A1 post spontaneous

delivery (day 2) O75.82

IUDZ97.5

ROB-ROD

2 LIS 33 March 30th 2015 P2A0 post spontaneous


IUDZ97.5

BOY-SUG

3 LIT 29 March 30th 2015 P2A0 post SSTP due to uterine

inversion (day 2) O75.82

IUDZ97.5

BOY-SUG

4 MAR 25 March 30th 2015 P2A1 post spontaneous


Impant InsertionZ30.49

BOY-SUG

5 ROS 29 March 30th 2015 P3A0 post spontaneous


Impant InsertionZ30.49

BOY-SUG

3

NOASSESMENT

dr. Hendra SugamaVALUE MAX Notes

1 Report technique 302 Paper acknowledgment 353 Honesty 35

Mean 100

4

TotalOBSTETRIC CASENo Initial Age Add Diagnosis ICD Code Treatment/Plan Physician1 TUT 28 UA

US

G1P0A0 38 weeks gestational age not inlabor with condiloma accuminata SLF cephalic presentation

36 weeks gestational age SLF cephalic presentation

Z.34078.11

- Sulfas ferrous 1x200mg

- Kalk 1x1 tablet - Recontrolled

within 1 week

FCH-SUG

2 ALI 29 UA

US

G7P5A1 35 weeks gestational age not inlabor SLF breech presentation

36 weeks gestational age SLF cephalic presentation

Z.34O80.1

- Sulfas ferrous 1x200mg


within 2 week

CGH-ROD

3 IND 25 UA

US

G2P1A0 18 weeks gestational age SLF intrauterine

17 weeks gestational age SLF intrauterine

Z.34 - Sulfas ferrous 1x200mg


within 1 month

FCH-SUG

4 SUL 28 UA

US




- Folic acid 1x400µg

- Neurodex tab 1x1- Kalk 1x1 tablet - Recontrolled

within 2 month

CGH-ROD

5 EVI 29 UA

US

G1P0A0 37 weeks gestational age not inlabor SLF cephalic presentation

37 weeks gestational age SLF cephalic presentation with amnion fluid thick and muddy + umbilical cord entanglement 1x



within 1 week- Consult to

Fetomaternal Supervisor, suggestion:- Admitted to

the hospital- Induction of

the labor

FCH-SUG

6 WID 29 UA

US





within 2 month

CGH-ROD

7 DWI 31 UA

US





within 2 months

FCH-SUG

LACTATION AND PUERPURALNo. Initial Age Add Diagnosis ICD Code Treatment/Plan Physician

5

1. NUR 23 RA P2A0 post LSCS due to macrosemia day 13rd

082.1 Roborantia ADS-??

2 YUL 23 UA P2A0 post LSCS due to macrosemia day 7th

082.1 Roborantia ADS-??

FAMILY PLANNING


(New/Old)/DateDiagnosis Contraception

Physician

1 ERN 22 April 24th 2015 P2A0 post spontaneous


Implant InsertionZ30.49

ADS-SUG

2 SIT 26 April 24th 2015 P2A0 post spontaneous


IUDZ97.5

ADS-SUG

3 VIT 27 April 24th 2015 P2A0 post spontaneous



ADS-SUG

4 WIW 20 April 24th 2015 P1A0 post spontaneous



ADS-SUG

5 SIN 20 April 27th 2015 P1A0 post spontaneous

preterm delivery (day 1) O60.10


ADS-SUG

6 NOV 28 April 27th 2015 P1A0 post spontaneous


IUDZ97.5

ADS-SUG

7 ELS 19 April 27th 2015 P1A0 post spontaneous


IUDZ97.5

ADS-SUG

8 SER 19 April 27th 2015 P1A0 post spontaneous


IUDZ97.5

ADS-SUG

6

chief report ob out 1 mei 2015.doc

Documents