A L
A N G
J l . R A YA P R O P P O P A M E U I V K A S A N
E m a i l : P u s k e s m a s P r o p p o t e r d e p a n @g m a i l . c o m
O :
0
1-3
4-6 A :
7-10
Skala Nyeri : .....................
Exposure
P :
Luka Ya Tidak. Rigio:
Fraktur Ya Tidak. Rigio:
Ter b u k a tertutup
Dislokasi Ya Tidak. Rigio:
Edema Ya Tidak
Kekuatan otot :
Rectal touche :
I.PEMERIKSAAN Dokter Tan g g a l / J a m :
Anamnesis (subyektif)
Pemeriksaan Fisik
L o k a s i Tra u m a
TERAPI/
JAM GCS TENSI SUHU NADI RR CAIRAN
INJEKSI
N a m a d a n Tan d a t a n g a n
Perawat
(..................................)
II.DIAGNOSA
KERJA/PRIMER :............................................................................ICD 10 :............................
.............................................................................ICD 10 :...........................
.............................................................................ICD 10 :...........................
III.TINDAKAN
1.........................................................................................................ICD 9 :............................
2.........................................................................................................ICD 9 :............................
3.........................................................................................................ICD 9 :............................
4.........................................................................................................ICD 9 :............................
I V.P E M E R I K S A A N P E N U N J A N G
V.T E R A P I
N a m a L e n g k a p d a n Tan d a t a n g a n
Dokter yang merawat
(................................... )
Tgl: ......../....../...............
Tgl : ........./.........../.........