Perencanaan(P) :_______________________________________________________
________________________________________________________
Nama&tanda tangan perawat
________________________
II. PENGKAJIAN DOKTER
Anamnesa(S)
Keluhan utama
:_______________________________________________________
________________________________________________________
Riwayat penyakit sekarang
:_______________________________________________________
Pemeriksaan(O)
Pemeriksaan fisik
Abdomen :_______________________________________________________
Auskultasi :_______________________________________________________
Pemeriksaan penunjang :
macam pemeriksaan Hasil
USG
Radiologi
EKG
Laboratorium
Diagnosa(A)
Diagnosa Kerja
:_______________________________________________________
Diagnosa Banding :______________________________________________________
Terapi(P) :_______________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Nama&tanda tangan
dokter
_______________________
LABEL NAMA
Nama :
………………………………………………………………………………………………………………
…………
Nama orang tua :
………………………………………………………………………………………………………………
…………
Alamat :…………………………………………………………
Tanggal Lahir : ………………………………… Umur :
…………………………….
No Telp :………………………………… Agama:
…………………………..
Pendidikan Terakhir: ……………………………….
Pekerjaan Terakhir :………………………………..
Keluhan :
………………………………………………………………………………………………………………
……….