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RUMAH SAKIT RM-MMC : 05.

20
MAYANG MEDICAL CENTRE
Jl. Ir. H. Juanda No. 56 Kel. Simp. III Mayang Mengurai Kec. Kota Baru Jambi 36126

No. RM : ...............
ASSESMEN MEDIS RAWAT INAP Nama : ...............
PASIEN THT Umur : ............
Alamat : ..........

Jenis Kelamin : ............. Ruang : ...............


Tgl. Masuk : ............. Kelas : ...............
DDJP : .............. PPJP : ..........
Diisi oleh Dokter
Tanggal :
I. STATUS GENERAL
A. ANAMNESA
1. Keluhan Utama
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2. Riwayat Penyakit Dahulu
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3. Riwayat Penyakit Sekarang
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4. Riwayat Penyakit Keluarga
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B. PEMERIKSAAN FISIK
1. Vital sign _______________________________________________________________________
2. Cranium _______________________________________________________________________
3. Leher _______________________________________________________________________
4. Thorax _______________________________________________________________________
5. Abdomen _______________________________________________________________________
6. Extremitas
a. Ex. Atas ________________________________________________________________
b. Ex. Bawah ________________________________________________________________
II. STATUS LOKALIS
a. Telinga Telinga Luar Daun Telinga :
Liang Telinga :
Telinga Tengan Membran Tympani :
Refleks Cahaya :
b. Hidung Hidung Luar
Hidung Dalam Cavum Nasi :
Concae Inferior:
Septum Nasi :
Pasase Udara :
c. Tenggorokan Tonsil
Daerah Posterior Farinx
Larinx Epiglotis :
Pita Suara :

d. Leher Pembesaran KGB :

e. Maksilo Facial Nervus Kranialis


Fraktur

Prima Dalam Pelayanan Mandiri Dalam Berkarya


III. DIAGNOSIS PENUNJANG
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IV. DIAGNOSIS
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V. TERAPI
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Nama & Tandatangan DPJP

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