STATUS PASIEN

I.

II.

IDENTITAS
1. Nama
2. Usia
3. Jenis Kelamin
4. Suku/Bangsa
5. Agama
6. Alamat
7. No. RM
8. Tanggal MRS

: .....................................................................................................................
: .....................................................................................................................
: Laki-laki/Perempuan
: .....................................................................................................................
: Islam/Katolik/Kristen/Buddha/Hindu/........................................................
: .....................................................................................................................
: .....................................................................................................................
: .....................................................................................................................

ANAMNESIS
Anamnesis dilakukan secara: autoanamnesis/aloanamnesis dengan ....................................
pada tanggal ........................................................ pukul....................................................................
1. Keluhan Utama : .....................................................................................................................
2. Riwayat Penyakit Sekarang
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3. Riwayat Penyakit Dahulu
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4. Riwayat Penyakit Keluarga dan Sosial Ekonomi
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5. Riwayat Kelahiran
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6. Riwayat Pemberian Makanan
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7. Riwayat Imunisasi
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8. Riwayat Tumbuh Kembang
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III.

PEMERIKSAAN FISIK
Pemeriksaan fisik dilakukan pada tanggal...................................pukul...............................
1. Keadaan Umum
2. Kesadaran
3. Tanda Vital
a. Tekanan darah
b. Nadi
c. Laju Nafas
d. Suhu
4. Antropometri
a. Berat badan
b. Tinggi badan
5. Status Gizi

: ....................................................................................................................
: ....................................................................................................................
:
: ............................. mmHg
: ............................ x/menit, .........................................................................
: ............................ x/menit, .........................................................................
: ............................ oC
:
: ....................................................................................................................
: ....................................................................................................................
: ....................................................................................................................
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6. Status Generalis :
a. Kulit
: ....................................................................................................................
b. Kepala
: ....................................................................................................................
c. Mata
: ....................................................................................................................
d. THT
: ....................................................................................................................
e. Leher
: ....................................................................................................................
f. Thoraks-Kardiovaskular
Inspeksi
: ....................................................................................................................
Palpasi
: ....................................................................................................................
Perkusi
: ....................................................................................................................
Auskultasi : ....................................................................................................................
g. Abdomen
Inspeksi
: ....................................................................................................................
Auskultasi : ....................................................................................................................
Palpasi
: ....................................................................................................................
Perkusi
: ....................................................................................................................
h. Uro-genital
: ....................................................................................................................
i. Anus/rektum : ....................................................................................................................
j. Ekstremitas
: ....................................................................................................................

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7. Status Lokalis

: ....................................................................................................................
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IV.

PEMERIKSAAN PENUNJANG
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V.

DAFTAR MASALAH
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VI.

DIAGNOSIS
Diagnosis kerja: .............................................................................................................................
Diagnosis banding : .......................................................................................................................
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VII.

TERAPI
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VIII.

PROGNOSIS
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