3 Kartu Berobat Lansia
3 Kartu Berobat Lansia
FAKULTAS KEDOKTERAN
UNIV. MUHAMMADIYAH PALEMBANG
KARTU BEROBAT
CATATAN MEDIS USIA LANJUT
No. ..... / ..... / ..... / 20...
Nama Pasien
TTL
Umur
: ....................................................................................................................... (L/P)
: ....................................................................................................................................
: ................................ Tahun
Tindakan Lab
INFORMASI PERSONAL
Status perkawinan :
Lajang
Menikah
Cerai Mati
Cerai Hidup
Pisah
Pendidikan :
Buta huruf
Tidak Tamat SD
Tidak Tamat SMP
Tidak Tamat SMA
Perguruan Tinggi
Pekerjaan:
Tidak Bekerja
Pelajar/Mahasiswa
Buruh
Tamat SD
Tamat SMP
Tamat SMA
Pegawai Swasta
Pegawai BUMN
Polri/ABRI
Pegawai Negeri
Pensiunan
Lainnya ..................................................
Agama :
Islam
Katolik
Prostestan
Hindu
Budha
Lainnya ..................................................................
Suku bangsa :
Melayu
Sunda
Batak
Jawa
Minang
Lainnya ................................................................
CATATAN KHUSUS
Riwayat penyakit dahulu :
Di rawat di RS, Alasan : .................................................................................................................
Tanggal rawat : .....................................................................................................
Di operasi,
Alasan : .................................................................................................................
Tanggal operasi : ..................................................................................................
Lainnya .............................................................................................................................................
..............
2. Penyakit tersering :
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Faktor risiko (alergi ) :
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Masalah sosial yang berat dalam keluarga :
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PEMERIKSAAN FISIK PERTAMA
BB
TB
TD
No.
: ................................. kg
: ................................. cm
: ................................. mmHg
Tanggal
SOAP
Diagnosis
(ICD)
Terapi
Pemeriksa
(TTD)
No.
Tanggal
SOAP
Diagnosis
(ICD)
Terapi
Pemeriksa
(TTD)