No.

RM :
RUMAH SAKIT UMUM DAERAH KOTA BOGOR
PEMERINTAH KOTA BOGOR
ASSESMENTRAWAT INAP
PASIEN PENYAKIT DALAM

DPJP :.....................................................................

Nama :Umur :
TTL :

PRuangan :

Alamat :

PPJP : .................................................
DIISI OLEH DOKTER

Tanggal :
A. ANAMNESA
1. Keluhaan utama
.............................................................................................................................................................................................
.............................................................................................................................................................................................
2. Riwayat penyakit dahulu
.............................................................................................................................................................................................
.............................................................................................................................................................................................
3. Riwayat Penyakit Sekarang
.............................................................................................................................................................................................
.............................................................................................................................................................................................
Riwayat penyakit keluarga
.............................................................................................................................................................................................
.............................................................................................................................................................................................
B. PEMERIKSAAN FISIK
1. Vital sign : ................................................................................................................................................................
2. Cratum : ..................................................................................................................................................................
..................................................................................................................................................................................
3. Leher
: ..................................................................................................................................................................
...................................................................................................................................................................................
4. Thorax : .................................................................................................................................................................
...................................................................................................................................................................................
4.

5.

Addomen : ...............................................................................................................................................................
..........................................................................................................................................................
........................................................................................................................................................

6.

Gemital
:...........................................................................................................................................................
..........................................................................................................................................................................
7. Etremitas : ..........................................................................................................................................................
A. Ex Atas : ........................................................................................................................................................
B. Ex Bawah : ........................................................................................................................................................
..............................................................................................................................................................................
C. DIAGNOSIS PENUNJANG
1. Laboratorium : ................................................................................................................................................
...............................................................................................................................................................................
2. Radiologo
: ................................................................................................................................................
...............................................................................................................................................................................
3. Diagnosis
: ................................................................................................................................................
................................................................................................................................................................................
D. DIAGNOSISI
..............................................................................................................................................................................
..............................................................................................................................................................................
E. TERAPI
...................................................................................................................................................................................
...............................................................................................................................................................................
Nama dan Tanda tangan DPJP

(..........................................)