RUMAH SAKIT MELATI Nama : ......

L P
Jln. Merdeka No. 92 Tangerang
Telp : (021) 5523945 (hunting), 55776739 Tgl. Lahir : ../../...ThB th bln
Fax. (021) 55769914, 5530670
Email : Info@rsmelati.co.id No. RM :
ASESMEN AWAL DOKTER SPESIALIS MATA
Pemeriksaan Tanggal : ............/........../............... Jam : ......................... Wib
1. ASESMEN PERAWAT Nama perawat : Tandatangan :

A. Data Subyektif: Ananmnese : ............................................................................................................................................

B. Riawayat Penyakit: ..............................................................................................................................................................
C. Data Obyektif :
KeadaanUmum: Baik Sedang Buruk KeadaanGizi : Baik Cukup Kurang
Tensi : /,mm.Hg Nadi :.x/mnt Suhu : c
Nafas :.x/mnt Skalanyeri :... BB:......kg
TB : ................................. Cm Kesadaran / gcs : ................................................................................................
2. ASESMEN DOKTER
A. Data Subyektif :
Keluhan utama : ..............................................................................................................................................................................
.........................................................................................................................................................................................................
Riwayat penyakit sekarang: ........................................................................................................... ................................................
.........................................................................................................................................................................................................
Riwayat penyakit dahulu : .................................................................................................................... ..........................................
Riwayat penyakit keluarga : ...........................................................................................................................................................
Riwayat Alergi : .............................................................................................................................................................................
B. Data Objektif :VOD: VOS : ..
Ukuran kaca mata lama
OD = ............................................... OS = ................................................Adisi= ......................................................
OD Kedudukan Bola Mata OS
Pergerakan

............................................................................. Palpebra .............................................................................

............................................................................. Konjungtiva .............................................................................
............................................................................. Kornea .............................................................................
............................................................................. Bilik mata depan .............................................................................
............................................................................. Iris dan Pupil .............................................................................
............................................................................. Lensa .............................................................................
............................................................................. Vitreous .............................................................................
.. fundus
............................................................................. Tekanan intra Okuler .............................................................................
Tes ishihara : normal red green deficiencies absolute colour blindness
Schimer test OD : ......................................................................... OS : ............................................................................
1. Status general :............................................................................................................................. ...........................................
2. Pemeriksaan penunjang : .......................................................................................................................................................
.........................................................................................................................................................................................................
Daftar masalah : ............................................................................................................................................ ..............................
.........................................................................................................................................................................................................
3. Diagnosis kerja : ......................................................................................................................................................................
Diagnosis banding : .................................................................................................................................................................
4. Rencana pemecahan masalah :
Planning :..................................................................................................................................................................................
Instruksi :..................................................................................................................................................................................
...................................................................................................................................................................................................
5. Rencana tindakan : .................................................................................................................................................................
Nama dokter : Tandatangan dokter :

Berilahtandaceklis () padakolom yang sesuai RJ-RM 08a/RSM/2016

Berilahtandasilang (X) padakolom yang tidaksesuai
Isilah ............ diatasdenganbenar
Berilahtandaceklis () padakolom yang sesuai RJ-RM 08a/RSM/2016
Berilahtandasilang (X) padakolom yang tidaksesuai
Isilah ............ diatasdenganbenar