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RS KHUSUS MATA MEDAN BARU

Jl. Abdullah Lubis No. 67 Medan Telp : 061 4530989 Fax : 061 4532924
Email : mbmc.mata@Yahoo.com

Asesmen IGD-1/2
CATATAN MEDIS GAWAT DARURAT
Accident Emergency Medical Record
1. Pengkajian Perawat/ Nurse Assement
A. Data Subyektif / Subjective Data :

Auto Anamnesa

Riwayat Alergi / History Of Allergy :

Allo Anamnesa

Tidak Ada
No

Ada, .............................................
Yes

Baik
Good

Sedang
Fair

Riwayat Penyakit Dulu / Past Disease History :


B. Data Objektif / Objective Data :
Keadaan Umum :
General Condition

Nilai nyeri / Pain Score


0
1
Tekanan Darah / Blood Pressure:
Pernapasan / Respiration :

Buruk
Baik

: (Tidak ada nyeri / no pain Nyeri Sangat berat / painfull)


2

3
4
mmHg
x/mnt

6
7
Nadi / pulse :

Berat badan / Weight :

Tanda Tangan & Nama Lengkap Perawat

10
x/mnt
Kg

Suhu / Temperature

Saturasi 02 / Saturation :

Tanggal / Date : .............................

C
%

Nurses Signature & Full Name

Jam / Time

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

RS KHUSUS MATA MEDAN BARU


Jl. Abdullah Lubis No. 67 Medan Telp : 061 4530989 Fax : 061 4532924
Email : mbmc.mata@Yahoo.com

Asesmen IGD-2/2
Tanggal / Date

Jam / Time

Nama Dokter /

Docter

Tanda Tangan :
NameSign

2. Pemeriksaan Dokter / Doctor Assessment


A. Anamnesa / Anamnesis :

B. Data Objektif / Objective Data :


Normal
Kepala / Head
Mata / Eyes
Mulut / Mouth
Leher / Neck
Dada / Chest
Perut / Abdomen
Alat Gerak / Extremities
Anus Genetella / Anogenital

Jika Tidak Normal, Jelaskan


If Not Normal, Please Explain

GCS : E ...... M ........ V .......

C. Diagnosa Kerja / Working Diagnosis :


................................................................................................................................................................
D. Diagnosa Banding / Differentlal Diagnosis :
...................................................................................................................................................................
E. Tindakan Pengobatan / Treatment Therapy :
...................................................................................................................................................................

F. Tindak Lanjut :
Follow Up
G. Kondisi Pulang

Condition Of Discharge
Tanggal / Date :

Pulang

Rawat

Pulang Paksa

Discharge

Inpatient

Refused Treatment

Rujuk
Referral

Meninggal
Death

Jam / Time

RS KHUSUS MATA MEDAN BARU


Jl. Abdullah Lubis No. 67 Medan Telp : 061 4530989 Fax : 061 4532924
Email : mbmc.mata@Yahoo.com

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