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FK.

UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

ANAMNESIS

RUA
NG

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

No. REK.
MED

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

NAM
A

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

UMUR / JK

: ..............
L/P

AGAMA

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

thn /

ALAMAT

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

PEKERJAAN

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

STATUS
PERKAWIN
AN

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

TGL.
PEMERIKSAAN

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

Dokter
Muda

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

I. ANAMNESIS
1. KELUHAN UTAMA
......................................................................................................
...............................
......................................................................................................
...............................
......................................................................................................
...............................
2. RIWAYAT PENYAKIT SEKARANG
......................................................................................................
...............................
......................................................................................................
...............................
......................................................................................................
...............................
......................................................................................................
...............................
......................................................................................................
...............................
3. RIWAYAT PENYAKIT / OPERASI DAHULU
......................................................................................................
...............................
......................................................................................................
...............................
......................................................................................................
...............................
......................................................................................................
...............................
......................................................................................................

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

...............................
4. RIWAYAT PENYAKIT PADA KELUARGA
......................................................................................................
...............................
......................................................................................................
...............................
......................................................................................................
...............................
5. RIWAYAT PEKERJAAN
......................................................................................................
...............................
......................................................................................................
...............................
......................................................................................................
...............................
6. RIWAYAT SOSIAL EKONOMI
......................................................................................................
...............................
......................................................................................................
...............................
......................................................................................................
...............................

PEMERIKSAA
N
FISIK

RUA
NG

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

NO. MED.
REK

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

NAM
A

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

Umur /
JK

: ............ .... thn


/ L/P

II. PEMERIKSAAN

FISIK

A. PEMERIKSAAN UMUM
Keadaan Umum

: Baik / Sedang / Buruk

Kesadaran

: G

Tinggi Badan / Berat Badan


BMI

...............

cm / ................

kg

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

Cara berjalan / Gait

gait
..............

Antalgik
: ..............................................................................

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

Hemiparese

gait

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

........

Steppage

gait

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

............

Parkinson

gait

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

...........

Tredelenberg

gait

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

......

Waddle

gait

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

...............

Lain -

lain

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

..................
Bahasa / Bicara

Komunikasi

verbal

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

...........

Komunikasi

nonverbal

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

..........
Tanda Vital

Tekanan darah

Nadi

Pernafasan

Suhu

:
:
:
:

Kulit
Status

Psikis

Sikap

mmHg
x /

x
o

menit

/ menit

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

Orientasi

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

Ekspresi

wajah

Perhatian : ...........................

Ekspresi

PEMERIKSAA
N
FISIK

wajah

RUA
NG

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

NO. MED.
REK

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

NAM
A

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

Umur /
JK

: ............ .... thn


/ L/P

B. Saraf - saraf Otak


Nervus

Kanan

Kiri
I.

N. Olfaktorius

.................

.................
II.

N. Opticus

.................

.................
III.

N. Occulomotorius

.................

.................
IV.

N. Trochlearis

.................

.................
V.

N. Trigeminus

.................

.................
VI.

N. Abducens

.................

.................
VII. N. Fascialis

.................

.................
VIII. N. Vestibularis

.................

.................
IX. N. Glossopharyngeus

.................

.................
X. N. Vagus
.................

.................

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

XI. N. Accesorius

.................

.................
XII. N. Hypoglosus

.................

.................
C. Kepala
Bentuk

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

.......................................
Ukuran

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

.......................................
Posisi

Mata

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

.............................

Hidung

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

.............................

Telinga

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

.............................

Mulut

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

.............................

Wajah

: simetris / asimetris

Gerakan
abnormal : .....................................................................................
.......................

PEMERIKSAA
N
FISIK

RUA
NG

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

NO. MED.
REK

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

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

NAM
A

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

Umur /
JK

: ............ .... thn


/ L/P

D. Leher
Inspeksi

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

..................................
Palpasi

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

...................................
Luas gerak sendi
Ante / Retrofleksi

( n 65 /

50 ) : .............. / ...............
Laterofleksi ( D / S )

( n 40 /

40 ) : ............. / ...............
Rotasi

(D / S )

( n 45 /

45 ) : ............. / ...............
Test provokasi
Lhermitte test / Spurling
Test Valsava

..................

Distraksi test
Test Nafziger :

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

...................

E. Thorak
Bentuk

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

.......................................
Pemeriksaan Ekspansi Thorak : Ekspirasi Maksimum ...... cm.
Inspirasi maksimum ..... cm
Paru Paru

Inspeksi

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

.........................

Palpasi
.........................

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

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

Perkusi

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

.........................

Auskultasi

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

........................
Jantung

Inspeksi

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

........................

Palpasi

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

........................

Perkusi

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

.........................

Auskultasi

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

.......................
Abdomen

Inspeksi

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

.......................

Palpasi

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

.......................

Perkusi

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

........................

Auskultasi

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

........................
PEMERIKSAA
N
RUA
: ........................

NO. MED.

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

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

NG
FISIK

NAM
A

........

REK

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

Umur /
JK

........
: ............ .... thn
/ L/P

G. Trunkus
Inspeksi

: Simetris

Deformitas

........................................................................................

..............................

Lordosis

.......................................................................................

...............................

Scoliosis

.......................................................................................

...............................

Gibbus

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

..............................
Hairy
spot

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

....................
Pelvic
Tilt

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

....................
Palpasi

Spasme otot otot para


vertebrae

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

Nyeri tekan
( lokasi )

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

............
Luas

gerak sendi lumbosacral

Ante / Retrofleksi ( 95 /
35 )

: ............................................................................
Laterofleksi ( D / S ) ( 40 /

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

40 )

: ............................................................................
Rotasi ( D / S ) ( 35 /

35 )

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

Test provokasi
Valsava test

: ................. Test Laseque : ....... / ....... Test

Baragard dan sicard : ...... / .......


Niffziger test
Oconnell

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

Test SLR

: ....... /........ Test

: ....... / ......

FNST

: ......... / ........ Test Patrick

Test Kontra Patrick

: ........ / ........

: ...... / .......

Test Gaenslen : ........ / ......... Test Thomas


Ober s

: ........ / ........ Test

: ...... / .......

Nachalas knee flexion test : ........ / .........

Mc. Bride sitting test

: ....... / ......
Yeomann s hyprextension

: ........ / .........

Mc. Bridge toe to

mouth sitting test : ....... / ......


Test
Schober : ...............................................................................................
........................
H. Anggota Gerak Atas
Inspeksi
Kiri
Deformitas
....................
Edema
....................
Tremor
....................
Nodus Heberden
...................

PEMERIKSAA
N
FISIK /
NEUROLOGI

Kanan
:

.......................

.......................

.......................

.......................

RUA
NG

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

NO. MED.
REK

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

NAM
A

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

Umur /
JK

: ............ .... thn


/ L/P

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

Neurologi
Motorik

Dextra

Sinistra
Gerakan

...................

...................
Kekuatan

...................

...................
Abduksi lengan

...................

Fleksi bahu

...................

Ekstensi siku

...................

Abduksi jari tangan

...................

...................
...................
...................
...................
Tonus

...................

...................
Tropi

...................

...................
Refleks fisiologis
Refleks tendon bisep

...................

Refleks tendon triseps

...................

...................
...................
Refleks patologis
Hoffman

...................

Tromner

...................

...................
...................
Sensorik
Protopatik

...................

...................
Proprioseptik
...................

...................

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

Vegetatif

...................

...................
Penilaian fungsi tangan

Dextra

Sinistra
Anatomical

...................

...................
Grips

...................

...................
Spread

...................

...................
Palmar abduct

...................

...................
Pinch

...................

...................
Lumbrical

...................

...................

PEMERIKSAA
N
FISIK / LGS

RUA
NG

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

NO. MED.
REK

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

NAM
A

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

Umur /
JK

: ............ .... thn


/ L/P

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

Luas gerak sendi

Aktif

Aktif

Pasif

Pasif

Abduksi bahu

Dextra
...............

Sinistra
...............

Dextra
...............

Sinistra
...............

Adduksi bahu

.
...............

...............

.
...............

...............

Fleksi bahu

.
...............

...............

.
...............

...............

Ekstensi bahu

.
...............

...............

.
...............

...............

Endorotasi bahu

( f0 )

.
...............

...............

.
...............

...............

Eksorotasi bahu

( f0 )

.
...............

...............

.
...............

...............

Endorotasi bahu

( f90 )

Eksorotasi bahu

( f90 )

Fleksi siku

...............

...............

...............

...............

Ekstensi siku

.
...............

...............

.
...............

...............

Ekstensi pergelangan tangan

.
...............

...............

.
...............

...............

Fleksi pergelangan tangan

.
...............

...............

.
...............

...............

Supinasi

.
...............

...............

.
...............

...............

Pronasi

.
...............

...............

.
...............

...............

.
Test Provokasi

.
Kanan

Kiri

Yergason test

...............

...............

Apley scratch test

...............

...............

Moseley test

...............

...............

Adson manuver

...............

...............

Tinel test

...............

...............

Phalen test

...............

...............

Prayer test

...............

...............

Finkelstein

...............

...............

Promet test

...............

...............

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

PEMERIKSAA
N
FISIK

RUA
NG

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

NO. MED.
REK

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

NAM
A

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

Umur /
JK

: ............ .... thn


/ L/P

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

I.
Anggota Gerak Bawah
Inspeksi
- Deformitas
- Edema
- Tremor
Palpasi
- Nyeri tekan ( lokasi )
- Diskrepansi
Neurologi
Motorik
Gerakan
Kekuatan
Fleksi paha
Ekstensi paha
Ekstensi lutut
Fleksi lutut
Dorsofleksi pergelangan

Kanan
...................
...................
...................
...................
...................
...................

Kiri
..................
..................
..................
..................
..................
..................

Kanan
...................

Kiri
..................

...................
...................
...................
...................
...................

..................
..................
..................
..................
..................

Dorsofleksi ibu jari

...................

..................

Plantar fleksi

...................

..................

...................
...................

..................
..................

...................

..................

...................

..................

...................
...................

..................
..................

:
:
:
:
:

kaki
kaki
pergelangan tangan
Tonus
Tropi
Reflkes fisiologis
Refleks tendo
patella
Refleks tendo achilles
Refleks patologi
Babinsky
Chaddock

PEMERIKSAA
N
FISIK / LGS

RUA
NG

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

NO. MED.
REK

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

NAM
A

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

Umur /
JK

: ............ .... thn


/ L/P

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

Sensorik
Protopatik
Proprioseptik
Vegetatif

Kanan
................
................
................

Luas gerak sendi

Kiri
................
................
................

Aktif

Aktif

Pasif

Pasif

Fleksi paha

Dextra
.............

Sinistra
.............

Dextra
.............

Sinistra
.............

Ekstensi paha

...
.............

...
.............

...
.............

...
.............

Endorotasi paha

...
.............

...
.............

...
.............

...
.............

Adduksi paha

...
.............

...
.............

...
.............

...
.............

Abduksi paha

...
.............

...
.............

...
.............

...
.............

Fleksi lutut

...
.............

...
.............

...
.............

...
.............

Ekstensi lutut

...
.............

...
.............

...
.............

...
.............

Dorsofleksi pergelangan kaki

...
.............

...
.............

...
.............

...
.............

Plantar fleksi pergelangan kaki

...
.............

...
.............

...
.............

...
.............

Inversi kaki

...
.............

...
.............

...
.............

...
.............

Eversi kaki

...
.............

...
.............

...
.............

...
.............

...

...

...

...
Test Provokasi
Stres test
Drawers test
Test tunel pada sendi lutut
Test homan
Test lain lain
PEMERIKSAA
N
FISIK

RUA
NG

Kanan
................
................
................
................
................

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

NO. MED.
REK

Kiri
................
................
................
................
................

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

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

NAM
A

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

Umur /
JK

: ............ .... thn


/ L/P

III. Pemeriksaan - Pemeriksaan lainnya


Pemeriksaan refleks refleks primitive pada anak anak dengan gangguan SSP
Righting reaction

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

Reaksi keseimbangan

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

Pemeriksaan lainnya

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

Bowel test / Bladder test


-

Sensorik perianal

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

Motorik sphinter ani

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

eksternus
BCR ( Bulbocapernosis

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

Refleks )
Fungsi luhur
-

........

Afasia

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

Apraksia

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

Agrafia

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

Alexia

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

IV. PEMERIKSAAN PENUNJANG


A. RADIOLOGIS

.......................................................................................................................
..............................
.......................................................................................................................
..............................
B. LABORATORIUM

.......................................................................................................................
..............................
.......................................................................................................................
..............................

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

C. LAIN LAIN CT - Scan /

MRI
.......................................................................................................................
..............................
.......................................................................................................................
..............................

RESUME

RUA
NG

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

NO. MED.
REK

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

NAM
A

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

Umur /
JK

: ............ .... thn


/ L/P

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

V. RESUME
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................
..................................................................................................................................
.................................

EVALUASI /
DIAGNOSIS

VI.

EVALUASI

RUA
NG

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

NO. MED.
REK

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

NAM
A

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

Umur /
JK

: ............ .... thn


/ L/P

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

N
O
1

Level ICF

Kondisi saat ini

Sasaran

Struktur dan fungsi

.....................................

.....................................

tubuh

.........

.........

.....................................

.....................................

.........

.........

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.........
.....................................

.........
.....................................

.........

.........

.....................................

.....................................

.........

.........

Aktivitas

Partisipasi

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK
.....................................

.....................................

.........

.........

.....................................

.....................................

.........

.........

.....................................

.....................................

.........

.........

.....................................

.....................................

.........

.........

.....................................

.....................................

..........
.........
Catatan : ICF ( International Clasification of Function / WH0 2002 )
DIAGNOSIS KLINIS
.....................................................................................................................................
................................
.....................................................................................................................................
................................

PEMERIKSAA
N
FISIK

RUA
NG

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

NO. MED.
REK

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

NAM
A

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

Umur /
JK

: ............ .... thn


/ L/P

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

VII. PROGRAM REHABILITASI MEDIK


Fisioterapi
Terapi panas
:
.....................................................................................
......................
.....................................................................................
......................
Terapi dingin

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

Stimulasi listrik

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

Terapi latihan
.....................................................................................
.....................
.....................................................................................
.....................
Okupasi Terapi
:
ROM exercise

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

ADL exercise
Ortotik Prostetik
Ortotic

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

Prostetic

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

Alat bantu
ambulasi
Terapi wicara
Afasia

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

Dysartria

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

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

Dysfagia

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

Social Medik

.....................................................................................
......................

Edukasi

.....................................................................................
......................

PEMERIKSAA
N
FISIK

RUA
NG

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

NO. MED.
REK

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

NAM
A

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

Umur /
JK

: ............ .... thn


/ L/P

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

VIII. TERAPI MEDIKAMENTOSA


...................................................................................................................................
.................................
...................................................................................................................................
.................................
...................................................................................................................................
.................................
...................................................................................................................................
.................................
...................................................................................................................................
.................................
...................................................................................................................................
.................................
...................................................................................................................................
.................................
...................................................................................................................................
.................................
...................................................................................................................................
.................................
...................................................................................................................................
.................................
...................................................................................................................................
.................................
...................................................................................................................................
.................................
IX. PROGNOSA
Medik

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

................

Fungsional

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

FK. UNSRI PALEMBANG

RM. R
BAGIAN REHABILITASI MEDIK

................
X. FOLLOW UP
Tanggal

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

...............
Keluhan

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

..............
Pemeriksaan
umum

: .........................................................................................................
Keadaan

khusus

: .........................................................................................................
Fungsional

Barthel index

FIM index

Katz index