IDENTITAS MAHASISWA

NAMA

TEMPAT/ TANGGAL LAHIR

NPM

ALAMAT

NAMA PUSKESMAS

LOKASI

CIREBON,

April 2016

FOTO BERWARNA
4X6

(.....)

KATA PENGANTAR
1

Blok HPK 264 merupakan implementasi dari beberapa area kompetensi pada Standar
Kompetensi Dokter Indonesia (KKI, 2006). Kegiatan pembelajaran keterampilan klinis di
Puskesmas merupakan sarana pembelajaran bagi mahasiswa agar mendapatkan pengalaman
belajar lapangan di dalam sistem pelayanan kesehatan yang secara nyata termuat dalam
kurikulum. Buku log ini adalah buku kegitan mahasiswa yang ditujukan sebagai salah satu
sumber untuk mengevaluasi pencapaian kompetensi mahasiswa.
Buku log ini juga dipergunakan untuk mengevaluasi program pendidikan. Oleh
karena itu mahasiswa juga diharapkan untuk menuliskan poin-poin penting dari kegiatan
pendidikan dan merefleksikan diri atas kemampuannya (baik kekurangan maupun
kelebihannya). Sedangkan pembimbing bertanggung jawab atas kegiatan mahasiswa
menuliskan umpan balik untuk kemajuan mahasiswa yang dibimbingnya. Buku log juga
dipergunakan sebagai salah satu sumber data bagi portofolio mahasiswa yang bersangkutan.

Penyusun

DAFTAR ISI

Identitas Mahasiswa.1
Kata Pengantar.2
Daftar isi..3
Kegiatan di Poliklinik Umum..4
Kegiatan di Poliklinik Konseling.6
Kegiatan di Posyandu Lansia8
Kegiatan di Pusling.. 10
Kegiatan di Farmasi..12
Home Visit Lansia.14
Format Penulisan Rekam medik............................................24
Lembar Penilaian Perilaku Profesional .........28
Lembar Penilaian Mini CEX.............29

KEGIATAN DI POLIKLINIK UMUM

No

Tgl

Identitas Pasien

Kegiatan

Paraf Instruktur

Anamnesis :

Pemeriksaan Fisik :

Diagnosis dan Diagnosis Banding :

Terapi

Anamnesis :

Pemeriksaan Fisik :

Diagnosis dan Diagnosis Banding :

Terapi

KEGIATAN DI POLIKLINIK UMUM

No

Tgl

Identitas Pasien

Kegiatan

Paraf Instruktur

Anamnesis :

Pemeriksaan Fisik :

Diagnosis dan Diagnosis Banding :

Terapi

Anamnesis :

Pemeriksaan Fisik :

Diagnosis dan Diagnosis Banding :

Terapi

KEGIATAN DI POLIKLINIK KONSELING

No

Tgl

Identitas Pasien

Kegiatan

Paraf Instruktur

Masalah :

Konseling :

Masalah :

Konseling :

Masalah :

Konseling :

KEGIATAN DI POLIKLINIK KONSELING

No

Tgl

Identitas Pasien

Kegiatan

Paraf Instruktur

Masalah :

Konseling :

Masalah :

Konseling :

Masalah :

Konseling :

KEGIATAN DI POSYANDU LANSIA

No

Tgl

Identitas Pasien

Kegiatan

Paraf Instruktur

Anamnesis :

Pemeriksaan Fisik :

Diagnosis dan Diagnosis Banding :

Terapi

Anamnesis :

Pemeriksaan Fisik :

Diagnosis dan Diagnosis Banding :

Terapi

KEGIATAN DI POSYANDU LANSIA

No

Tgl

Identitas Pasien

Kegiatan

Paraf Instruktur

Anamnesis :

Pemeriksaan Fisik :

Diagnosis dan Diagnosis Banding :

Terapi

Anamnesis :

Pemeriksaan Fisik :

Diagnosis dan Diagnosis Banding :

Terapi

KEGIATAN DI PUSLING
No

Tgl

Identitas Pasien

Kegiatan

Paraf Instruktur

Anamnesis :

Pemeriksaan Fisik :

Diagnosis dan Diagnosis Banding :

Terapi

Anamnesis :

Pemeriksaan Fisik :

Diagnosis dan Diagnosis Banding :

Terapi

KEGIATAN DI PUSLING
No

Tgl

Identitas Pasien

Kegiatan

Paraf Instruktur

10

Anamnesis :

Pemeriksaan Fisik :

Diagnosis dan Diagnosis Banding :

Terapi

Anamnesis :

Pemeriksaan Fisik :

Diagnosis dan Diagnosis Banding :

Terapi

KEGIATAN DI FARMASI
No

Tgl

Identitas Pasien

Kegiatan

Paraf Instruktur

11

Diagnosis dan Diagnosis Banding :

Terapi :

Diagnosis dan Diagnosis Banding :

Terapi :

Diagnosis dan Diagnosis Banding :

Terapi :

KEGIATAN DI FARMASI
No

Tgl

Identitas Pasien

Kegiatan

Paraf Instruktur

12

Diagnosis dan Diagnosis Banding :

Terapi :

Diagnosis dan Diagnosis Banding :

Terapi :

Diagnosis dan Diagnosis Banding :

Terapi :

HOME VISIT LANSIA

Tanggal :

13

Nama

GERIATRIC ASSESSMENT CENTER

ACTIVITIES OF DAILY LIVING
PHYSICAL SELF-MAINTENANCE SCALE

Instructions: Write in the appropriate value number on the score lines provided to the right
of the responses. Add the value numbers to obtain total score.
1. TOILET
4 Cares for self at toilet completely, no incontinence
3 Needs to be reminded, or needs help in cleaning self, or has
rare (weekly at most) accidents
2 Soiling or wetting while asleep, more than once a week
1 Soiling or wetting while awake, more than once a week
0 No control of bowels or bladder

Value No

2. FEEDING
4 Eats without assistance
3 Eats with minor assistance at meal times, with help preparing
food or with help in cleaning up after meals
2 Feeds self with moderate assistance and is untidy
1 Requires extensive assistance for all meals
0 Does not feed self at all and resists efforts of others to feed him

Value No

3. DRESSING
4 Dresses, undressed and selects clothes from own wardrobe
3 Dresses and undresses self, with minor assistance
2 Needs moderate assistance in dressing or selection of clothes
1 Needs major assistance in dressing but cooperated
with efforts of other to help
0 Completely unable to dress self and resists efforts of others to help

Value No

4. GROOMING
4 Always neatly dressed and well-groomed, without assistance
3 Grooms self adequately, with occasional minor assistance
2 Needs moderate and regular assistance or supervision in grooming
1 Needs major assistance in dressing but cooperates
with efforts of others to help
0 Actively negates all efforts to others to maintain grooming

Value No

5. PHYSICAL AMBULATION
4 Goes about grounds or city
3 Ambulates within residence or about one block distant
2 Ambulates with assistance of (check one):

Value No

14

____another person, ____ railing, ____ cane, ____

walker,or ____ wheelchair: ____ gets in and out without help ____
needs help in getting in and out
1 Sits unsupported in chair or wheelchair, but cannot propel self without help
0 Bedridden more than half the time
6. BATHING
4 Bathes self (tub, shower, sponge bath) without help
3 Bathes self, with help in getting in and out of tub
2 Washes face and hands only, but cannot bathe rest of body
1 Does not wash self but is cooperative with those who bathe him
0 Does not travel at all

Value No

7. RESPONSIBILITY FOR OWN MEDICATION

2 Is responsible for taking medication in correct dosages at correct time
1 Takes responsibility if medication is prepared in advance
in separate dosages
0 Does not try to wash self, and resists efforts to keep him clean

Value No

TOTAL SCORE :

GERIATRIC ASSESSMENT CENTER

SCALE FOR INSTRUMENTAL
ACTIVITIES OF DAILY LIVING

15

1. ABILITY TO USE TELEPHONE

3 Operates telephone on own initiative; looks up
and dials numbers, etc.
2 Dials a few well known numbers
1 Answers telephone but does not dial
0 Does not use telephone at all

Value No

2. SHOPPING
3 Takes care of all shopping needs independently
2 Shops independently for small purchases
1 Needs to be accompanied on any shopping trip
0 Needs to have meals prepared and served

Value No

3. FOOD PREPARATION
3 Plans, prepares and serves adequate meals independently
2 Prepares adequate meals if supplied with ingredients
1 Heats and serves prepared meals, or prepares meals but does not
maintain adequate diet
0 Needs to have meals prepared and served

Value No

4. HOUSE KEEPING
4 Maintains house alone or with occasional assistance
(e.g., heavy-work domestic help)
3 Performs light daily tasks such as dish-washing and bed-making
2 Performs light daily tasks but cannot maintain acceptable \
level of cleanliness
1 Needs help with all home maintenance tasks
0 Does not participate in any housekeeping tasks

Value No

5. LAUNDRY
2 Does personal laundry completely
1 Launders small items; rinses socks, stockings, etc.
0 All laundry must be done by others
6. MODE OF TRANSPORTATION
4 Travels independently on public transportation or drives own car
3 Arranges own travel via taxi, but does not otherwise use
public transportation
2 Travels on public transportation when assisted or
accompanied by another
1 Travel limited to taxi or automobile, with assistance of another
0 Does not travel at all

Value No

Value No

7. RESPONSIBILITY OF OWN MEDICATION

2 Is responsible for taking medication in correct dosages at correct time
1 Takes responsibility if medication is prepared in advance
in separate dosages
0 Is not capable of dispensing own medication

Value No

16

8. ABILITY TO HANDLE FINANCE

2 Manages financial matters independently
(budgets, write checks, pays rent and bills, goes toBank)
collects and keeps track of income
1 Manages day-to-day purchases, but needs help with banking,
major purchases, etc.
0 Incapable of handling money

Value No

TOTAL SCORE

Peran Keluarga

17

Peran Lingkungan

Feedback Pembimbing

HOME VISIT LANSIA

Tanggal :

18

Nama

GERIATRIC ASSESSMENT CENTER

ACTIVITIES OF DAILY LIVING
PHYSICAL SELF-MAINTENANCE SCALE

Instructions: Write in the appropriate value number on the score lines provided to the right
of the responses. Add the value numbers to obtain total score.
1. TOILET
4 Cares for self at toilet completely, no incontinence
3 Needs to be reminded, or needs help in cleaning self, or has
rare (weekly at most) accidents
2 Soiling or wetting while asleep, more than once a week
1 Soiling or wetting while awake, more than once a week
0 No control of bowels or bladder

Value No

2. FEEDING
4 Eats without assistance
3 Eats with minor assistance at meal times, with help preparing
food or with help in cleaning up after meals
2 Feeds self with moderate assistance and is untidy
1 Requires extensive assistance for all meals
0 Does not feed self at all and resists efforts of others to feed him

Value No

3. DRESSING
4 Dresses, undressed and selects clothes from own wardrobe
3 Dresses and undresses self, with minor assistance
2 Needs moderate assistance in dressing or selection of clothes
1 Needs major assistance in dressing but cooperated
with efforts of other to help
0 Completely unable to dress self and resists efforts of others to help

Value No

4. GROOMING
4 Always neatly dressed and well-groomed, without assistance
3 Grooms self adequately, with occasional minor assistance
2 Needs moderate and regular assistance or supervision in grooming
1 Needs major assistance in dressing but cooperates
with efforts of others to help
0 Actively negates all efforts to others to maintain grooming

Value No

5. PHYSICAL AMBULATION
4 Goes about grounds or city
3 Ambulates within residence or about one block distant
2 Ambulates with assistance of (check one):

Value No

19

____another person, ____ railing, ____ cane, ____

walker,or ____ wheelchair: ____ gets in and out without help ____
needs help in getting in and out
1 Sits unsupported in chair or wheelchair, but cannot propel self without help
0 Bedridden more than half the time
6. BATHING
4 Bathes self (tub, shower, sponge bath) without help
3 Bathes self, with help in getting in and out of tub
2 Washes face and hands only, but cannot bathe rest of body
1 Does not wash self but is cooperative with those who bathe him
0 Does not travel at all

Value No

7. RESPONSIBILITY FOR OWN MEDICATION

Value No

2 Is responsible for taking medication in correct dosages at correct time

1 Takes responsibility if medication is prepared in advance
in separate dosages
0 Does not try to wash self, and resists efforts to keep him clean

TOTAL SCORE :

GERIATRIC ASSESSMENT CENTER

SCALE FOR INSTRUMENTAL
ACTIVITIES OF DAILY LIVING

20

1. ABILITY TO USE TELEPHONE

3 Operates telephone on own initiative; looks up
and dials numbers, etc.
2 Dials a few well known numbers
1 Answers telephone but does not dial
0 Does not use telephone at all
2. SHOPPING
3 Takes care of all shopping needs independently
2 Shops independently for small purchases
1 Needs to be accompanied on any shopping trip
0 Needs to have meals prepared and served

Value No

Value No

3. FOOD PREPARATION
3 Plans, prepares and serves adequate meals independently
2 Prepares adequate meals if supplied with ingredients
1 Heats and serves prepared meals, or prepares meals but does not
maintain adequate diet
0 Needs to have meals prepared and served

Value No

4. HOUSE KEEPING
4 Maintains house alone or with occasional assistance
(e.g., heavy-work domestic help)
3 Performs light daily tasks such as dish-washing and bed-making
2 Performs light daily tasks but cannot maintain acceptable \
level of cleanliness
1 Needs help with all home maintenance tasks
0 Does not participate in any housekeeping tasks

Value No

5. LAUNDRY
2 Does personal laundry completely
1 Launders small items; rinses socks, stockings, etc.
0 All laundry must be done by others
6. MODE OF TRANSPORTATION
4 Travels independently on public transportation or drives own car
3 Arranges own travel via taxi, but does not otherwise use
public transportation
2 Travels on public transportation when assisted or
accompanied by another
1 Travel limited to taxi or automobile, with assistance of another
0 Does not travel at all

Value No

Value No

7. RESPONSIBILITY OF OWN MEDICATION

2 Is responsible for taking medication in correct dosages at correct time
1 Takes responsibility if medication is prepared in advance
in separate dosages
0 Is not capable of dispensing own medication

Value No

21

8. ABILITY TO HANDLE FINANCE

2 Manages financial matters independently
(budgets, write checks, pays rent and bills, goes toBank)
collects and keeps track of income
1 Manages day-to-day purchases, but needs help with banking,
major purchases, etc.
0 Incapable of handling money

Value No

TOTAL SCORE

Peran Keluarga

22

Peran Lingkungan

Feedback Pembimbing

FORMAT PENULISAN REKAM MEDIK

I. IDENTITAS PASIEN
23

Tanggal
Nama
Jenis kelamin
Umur
Status keluarga
Alamat

:
:
:
:
:
:

Suku bangsa
Agama
Pekerjaan
Orang yang dapat dihubungi

:
:
:
:

No. Catatan Medik

II. ANAMNESA (Subjective)

1.

2.

Keluhan utama

Keluhan tambahan

Riwayat Penyakit Sekarang :

Riwayat Penyakit Dahulu

3.

Riwayat Penyakit Keluarga

24

1. Riwayat Pribadi dan Sosial

2. Tinjauan Sistem Tubuh

I. PEMERIKSAAN FISIK (Objective)

A. Keadaan Umum

B. Kesadaran

C. Vital sign

:T

mmHg

x/menit

x/menit.

Status Generalis
A. Kepala
Rambut

:
:

B. Pemeriksaan Mata
Palpebra

Konjungtiva

Sklera

Pupil

C. Pemeriksaan Telinga

D. Pemeriksaan Hidung

E. Pemeriksaan Mulut

F.

Pemeriksaan Leher

25

Trakhea

Kelenjar thyroid

JVP

G. Pemeriksaan Kulit

H. Pemeriksaan Dada

Pulmo
Inspeksi

Palpasi

Perkusi

Auskultasi

Jantung
Inspeksi

Palpasi

Perkusi

Auskultasi

I. Pemeriksaan Abdomen
Inspeksi

Auskultasi

Perkusi

Palpasi

26

J. Ekstremitas
Superior
Inferior

:
:

Status Lokalis

II. ASSESSMENT
Diagnosis Differensial :

Diagnosis :

III. PLANNING
a. Initial Planning Diagnosis (Ip Dx)

b. Initial Planning Terapi (Ip Th)

c. Initial Planning Monitoring (Ip Mx)

d. Initial Planning Edukasi (Ip Ed)

27

LEMBAR PENILAIAN PERILAKU PROFESIONAL

NO

Aspek yang dinilai

Jujur

Bertanggung jawab

Compassion

Baik

Cukup

Kurang

28

Mawas diri

Hubungan dokter-pasien

Tidak diskriminatif

Partisipasi

Cirebon,

April 2016

Mengetahui,
Pembimbing Puskesmas

PENILAIAN MINI CEX

FORM PENILAIAN PENGELOLAAN PASIEN GERIATRI (1)
Puskesmas :
Penilai
:
Tanggal
:
Mahasiswa :
Problem Pasien/Diagnosis :
Jenis kelamin : L/P
Tingkat kerumitan :__Rendah

Umur :
__Sedang

__Tinggi

29

Fokus

__Data gathering

__Diagnosis

__Terapi

__Konseling

1. KETERAMPILAN ANAMNESA
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Interview/anamnesa pasien secara lengkap, tepat, sistematis, dan dicatat
secara terperinci
2. KETERAMPILAN PEMERIKSAAN FISIK
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Melakukan pemeriksaan dengan teliti, urutan logis, memenuhi
urutan langkah-langkah
diagnostik, informed consent pada pasien
3. KUALITAS HUMANISTIK/PROFESIONALISME
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Mempunyai perhatian, rasa hormat, empati, menjaga rahasia,
memperhatikan kenyamanan pasien
4. KETERAMPILAN KONSELING
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Menjelaskan/menginformasikan tentang tes/terapi pada pasien,
memperoleh persetujuan pasien (konseling, informasi, edukasi)

5. KEPUTUSAN KLINIS/DIAGNOSIS
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Mensintesis data, menentukan diagnosa, diagnosa differensial,
manajemen
6. ORGANISASI/EFISIENSI
1
2
3
4
5
Sangat kurang
Kurang
baik
Tepat waktu, singkat, dan jelas

6
7
Borderline

8
cukup

30

7. KOMPETENSI KLINIK SECARA KESELURUHAN

1
2
3
4
5
Sangat kurang
Kurang
baik

6
7
Borderline

8
cukup

Cirebon,

April 2016

Mengetahui,
Pembimbing Puskesmas

PENILAIAN MINI CEX

FORM PENILAIAN PENGELOLAAN PASIEN GERIATRI (2)
Puskesmas
Penilai

:
:

31

Tanggal
:
Mahasiswa :
Problem Pasien/Diagnosis :
Jenis kelamin : L/P
Tingkat kerumitan :__Rendah
Fokus
:
__Data gathering

Umur :
__Sedang
__Diagnosis

__Tinggi
__Terapi
__Konseling

1. KETERAMPILAN ANAMNESA
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Interview/anamnesa pasien secara lengkap, tepat, sistematis, dan dicatat
secara terperinci
2. KETERAMPILAN PEMERIKSAAN FISIK
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Melakukan pemeriksaan dengan teliti, urutan logis, memenuhi
urutan langkah-langkah
diagnostik, informed consent pada pasien
3. KUALITAS HUMANISTIK/PROFESIONALISME
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Mempunyai perhatian, rasa hormat, empati, menjaga rahasia,
memperhatikan kenyamanan pasien
4. KETERAMPILAN KONSELING
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Menjelaskan/menginformasikan tentang tes/terapi pada pasien,
memperoleh persetujuan pasien (konseling, informasi, edukasi)

5. KEPUTUSAN KLINIS/DIAGNOSIS
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Mensintesis data, menentukan diagnosa, diagnosa differensial,
manajemen

32

6. ORGANISASI/EFISIENSI
1
2
3
4
5
Sangat kurang
Kurang
baik
Tepat waktu, singkat, dan jelas
7. KOMPETENSI KLINIK SECARA KESELURUHAN
1
2
3
4
5
Sangat kurang
Kurang
baik

6
7
Borderline

8
cukup

6
7
Borderline

8
cukup

Cirebon,

April 2016

Mengetahui,
Pembimbing Puskesmas

PENILAIAN MINI CEX

33

FORM PENILAIAN PENGELOLAAN PASIEN GERIATRI (3)

Puskesmas :
Penilai
:
Tanggal
:
Mahasiswa :
Problem Pasien/Diagnosis :
Jenis kelamin : L/P
Tingkat kerumitan :__Rendah
Fokus
:
__Data gathering

Umur :
__Sedang
__Diagnosis

__Tinggi
__Terapi
__Konseling

1. KETERAMPILAN ANAMNESA
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Interview/anamnesa pasien secara lengkap, tepat, sistematis, dan dicatat
secara terperinci
2. KETERAMPILAN PEMERIKSAAN FISIK
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Melakukan pemeriksaan dengan teliti, urutan logis, memenuhi
urutan langkah-langkah
diagnostik, informed consent pada pasien
3. KUALITAS HUMANISTIK/PROFESIONALISME
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Mempunyai perhatian, rasa hormat, empati, menjaga rahasia,
memperhatikan kenyamanan pasien
4. KETERAMPILAN KONSELING
1
2
3
4
5
6
7
8
9
Sangat kurang
Kurang
Borderline
cukup
baik
Menjelaskan/menginformasikan tentang tes/terapi pada pasien,
memperoleh persetujuan pasien (konseling, informasi, edukasi)

5. KEPUTUSAN KLINIS/DIAGNOSIS
1
2
3
4

9
34

Sangat kurang
Kurang
Borderline
cukup
baik
Mensintesis data, menentukan diagnosa, diagnosa differensial,
manajemen
6. ORGANISASI/EFISIENSI
1
2
3
4
5
Sangat kurang
Kurang
baik
Tepat waktu, singkat, dan jelas
7. KOMPETENSI KLINIK SECARA KESELURUHAN
1
2
3
4
5
Sangat kurang
Kurang
baik

6
7
Borderline

8
cukup

6
7
Borderline

8
cukup

Cirebon,

April 2016

Mengetahui,
Pembimbing Puskesmas

35