Nama : :

Tgl : :
Lahir/Umur : :
ASESMEN MEDIS No RM : :
RAWAT INAP GERIATRI Jenis Kelamin : : Ruang :
Tgl Masuk : : Kelas :
DPJP : :
PPJP : :
Diisi oleh Dokter
Tanggal :
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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5. Riwayat sosial ekonomi dan lingkungan
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6. Masalah Psikologi dan Fungsi:
a. ADL Index KATZ :
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b. Resiko Dekubitus/Skor Northon
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c. Skor Depresi
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d. Skor Minimental
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e. Status Gizi
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7. PEMERIKSAAN PENYARING TERHADAP KONDISI GERIATRI
PROBLEM HASIL
Penglihatan
Pendengaran
Mobilitas Kaki
t
Inkontinensia urin
Memori
Keterbatasan Fisik
B. PEMERIKSAAN FISIK
1. Vital Sign :
2. Cranium..................................................................................................................................................................................
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3. Mata..................................................................................................................................................................... .................
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4. THT..................................................................................................................................................................... ..................
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5. Leher..................................................................................................................................................................... .................
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6. Thorax...............................................................................................................................................................
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7. Jantung..................................................................................................................................................................... .............
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8. Paru..................................................................................................................................................................... ..................
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9. Abdomen.................................................................................................................................................................... ...........
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10. Ekstrimitas
Ekstrimitas Superior Inferior
Oedeme
Kekuatan
Clubbing finger
Os Genu

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1. PEMERIKSAAN PENUNJANG
1. Laboratorium:......................................................................................................................................................................
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2. Radiologi.............................................................................................................................................................................
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3. ECG....................................................................................................................................................................................
4. Lain - lain............................................................................................................................................................................
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2. DIAGNOSIS


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3. TERAPI

Tanda tangan DPJP

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