RUMAH SAKIT UMUM DAERAH ULIN BANJARMASIN

JALAN A. YANI NO. 43

TELP. (0511) 3252180
SMF ILMU PENYAKIT DALAM

DATA MEDIS PASIEN

Nama Lengkap : …………………………………………………………………………………………………………………………………………..
Tanggal Lahir : …………………………………………......... Umur : ……………Tahun Jenis Kelamin : L / P
Alamat : ………………………………………………………………………………………………….. Nomor Telepon : ……………….....

Pekerjaan : ………………………………………………………. Status : Belum menikah/ Menikah / Janda / Duda

Pendidikan : ……………………………… Etnis / Suku : ……………………………. Agama : ……………………………………..

Dokter Muda : ……………………………………………………………

Dokter : ……………………………………………………………………..
ANAMNESIS Tanggal :………………………………………..... Jam : ………………
Autoanamnesis Heteroanamnesis
RIWAYAT PENYAKIT SEKARANG
Keluhan utama : _______________________________________________________________________
Deskripsi : ____________________________________________________________________________
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RIWAYAT PENYAKIT DAHULU

Tanggal Penyakit Tempat Perawatan Pengobatan dan

Operasi

RIWAYAT KELUARGA Laki – laki Perempuan

X Meninggal (sebutkan sebab meninggal dan umur saat meninggal)

Kakek - Nenek

Ayah - Ibu

Pasien

Anak

RIWAYAT PRIBADI
Riwayat Alergi Riwayat Imunisasi
Tahun Bahan / Obat Gejala Tahun Jenis imunisasi

Hobi : ____________________________________________________________________________
Olah raga : ________________________________________________________________________
Kebiasaan makan : __________________________________________________________________
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Merokok : _________________________________________________________________________
Minum Alkohol : __________________________________________________________________
Hubungan seks : __________________________________________________________________

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ANAMNESIS UMUM (Review of Systems)
Berilah tanda bila abnormal dan berikan deskripsi
Umum Lelah ______________________________________
Penurun BB _________________________________
Demam ____________________________________
Mengigil ___________________________________
Berkeringat ________________________________
Kulit Rash _____________________________________
Gatal _____________________________________
Luka _____________________________________
Tumor ____________________________________
Kepala dan Leher
Sakit Kelapa ________________________________
Nyeri _____________________________________
Kaku leher __________________________________
Trauma ____________________________________
Mata Kaca mata __________________________________
Gatal ______________________________________
Ikterus ____________________________________
Merah_____________________________________
Nyeri ______________________________________
Diplopia ___________________________________
Visus ______________________________________
Telinga Pendegaran _________________________________
Infeksi _____________________________________
Nyeri ______________________________________
Tinnitus ____________________________________
Vertigo ____________________________________
Hidung Sekret _____________________________________
Kering _____________________________________
Berdarah ___________________________________
Nyeri ______________________________________
Buntu _____________________________________
Berbau ___________________________________
Halusinasi _________________________________
Bersin – bersin _____________________________
Mulut dan Tenggorokan
Nyeri _____________________________________
Kering _____________________________________
Suara serak _________________________________
Menelan ___________________________________
Sakit menelan _______________________________
Gigi _______________________________________
Gusi _______________________________________
Infeksi _____________________________________
Pernafasan
Batuk ____________________________________
Riak _____________________________________
Nyeri _____________________________________
Mengi (wheezing) ___________________________
Sesak nafas ________________________________
Hemoptisis ________________________________
Pncumonia ________________________________
Nyeri plueritik ______________________________
Tuberkulosis ________________________________
Payudara Sekret ___________________________________
Nyeri _____________________________________
Benjolan ___________________________________
Perdarahan ________________________________
Infeksi ____________________________________
Jantung Angina____________________________________
Sesak nafas ________________________________
Ortopnea __________________________________
Paraxysmal mocturnal dyspnea _________________
Edema ____________________________________
Murmur ___________________________________
Palpitasi ___________________________________
Infark ______________________________________
Hepertensi _________________________________
Vaskuler Klaudikasio _________________________________
Flebitis _____________________________________
Ulkus ______________________________________
Arteritis ___________________________________
Vena varicose _______________________________
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Abdomen Nafsu makan______________________________
Anoreksia ________________________________
Mual ____________________________________
Muntah __________________________________
Pendrahan ______________________________
Melena __________________________________
Nyeri ____________________________________
Diare ____________________________________
Konstipasi _______________________________
Buang air besar ____________________________
Hemoroid ________________________________
Hernia___________________________________
Hepatitis ________________________________
Ginekologi Perdarahan _______________________________
Spotting _________________________________
Sekret ___________________________________
Gatal ____________________________________
Penyakit kelamin ___________________________
Kontrasepsi ______________________________
Menarche_______________________________
Siklus haid _______________________________
Menopause ______________________________
Kehamilan _______________________________
Prematur ________________________________
Abortus _________________________________
Pap smear _______________________________
Alat kelamin laki – laki
Nyeri ___________________________________
Gatal ___________________________________
Sekret __________________________________
Penyakit kelamin ___________________________
Ulkus ____________________________________
Gatal ____________________________________
Ereksi ____________________________________
Ginjal dan Saluran Kencing
Disuri ___________________________________
Hematuri________________________________
Inkontinensa______________________________
Nokturia _________________________________
Frekuensi ________________________________
Batu ____________________________________
Infeksi __________________________________
Hematologi
Anemia___________________________________
Perdarahan ______________________________
Endokrin / Metabolik
Diabetes _________________________________
Perubahan berat badan _____________________
Goiter ___________________________________
Tleransi terhadap temperatur ________________
Asupan cairan _____________________________
Muskuloskeletal
Trauma _________________________________
Nyeri ___________________________________
Kaku_____________________________________
Bengkak __________________________________
Lemah __________________________________
Nyeri punggung ___________________________
Kram ___________________________________
Sistem syaraf
Sinkop ___________________________________
Kejang ___________________________________
Temor ___________________________________
Nyeri ___________________________________
Sensorik __________________________________
Tenaga ___________________________________
Daya ingat ________________________________
Emosi Kecemasan ______________________________
Tidur ___________________________________
Depresi __________________________________
Halusinasi _______________________________
PEMERIKSAAN FISIK
DESKRIPSI UMUM
Kesan sakit :
Gizi :
Berat Badan : …………………….. kg ; Tinggi badan : ……………………………………. Cm; IMT : …………………………. Kg / m2
TANDA VITAL
Kesadaran
Nadi
Tekanan darah
(mmHg)
Temperatur
(0 Celcius)
Pernafasan
KULIT
Inspeksi : pigmentasi,
tekstur, turgor, rash,
infeksi, tumor, petekie
hematom, ekskoriasi,
ikterus, kuku, rambut
Palpasi : nodul, atrofi,
Sklerosis
KEPALA dan LEHER
Inspeksi : bentuk kepala,
Sikatrik, pembengkakan
Palpasi : kelenjar limfe,
Pembengkakan, nyeri tekan,
Tiroid, trakea, pulsasi vena
Auskultasi : bruit
Pemeriksaan : JVP, kaku
Kuduk
TELINGA
Inspeksi : serum, infeksi,
Membrane timpani, tophi
Palpasi : mastoid, massa
HIBUNG
Inspeksi : septum, mukosa,
Secret, perdarahan, polip
Palpasi : nyeri
RONGGA MULUT dan
TENGGOROKAN
Inspeksi : pigmentasi
Leukoplakia, ulkus, tumor,
Gusi, gigi, infeksi, lidah
Faring, tomsil
Palpasi : nyeri, tumor,
Kelenjar ludah
4
Ringan Sedang Berat
Frekuensi : / menit Deskripsi :
Berbaring Duduk :
Lengan kanan : Lengan kanan :
Lengan kiri : Lengan kri :
Aksila : Rektal :
Frekuensi : / menit Deskripsi
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MATA
Inspeksi : ptosis, sklera,
Ikterus, puat, kornea, arkus,
Merah, infeksi, air mata,
Tumor, perdarahan,
Pupil (kanan / kiri), lapangan
Pandang
Palpasi : tonometri
(kanan / kiri)
Funduskopi (kanan / kiri)
TORAKS
Inspeksi : simetri, gerakan,
Repirasi, irama,payudara,
Tumor
Palpasi : gerakan, fremitus
fokal
Perkusi : resonansi
Auskultasi : suara nafas,
Rales, ronki, wheezing
Brankofoni, pectoriloquy
JANTUNG
Inspeksi : iktus
Palpasi : iktus, thrill
Perkusi : batas kiri, batas
Kanan, pinggang jantung
Auskultasi : denyut jantung
(frekuensi, irama) S1, S2
S3, S4, gallop, murmur,
Efection click, rub
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ABDOMEN
Inspeksi : kontur, striac
Sikatrik, vena, caput
Medusa, hernia
Palpasi : nyeri, defance
Rigiditas, massa, henia,
Hati, limpa, ginjal
Perkusi : resonansi, shifting
Dullness, undulasi
Perkusi: peristaltic usus,
Bruit, rub
PUNGGUNG
Inspeksi : postur, mobilitas,
Skoliosis, kifosis, lordosis
Palpasi : nyeri, gybus,
Tumor
EKSTREMITAS
Inspeksi : gerak sendi,
Pembengkakan, merah,
Deformitas, simetri, edema,
Sionasis, pucat, ulkus,
Varises, kuku
Palpasi : panas, nyeri,
Massa, edema, denyut nadi
Perifer
ALAT KELAMIN
Laki – laki : sirkumsisi, rash, _____________________________________________________________
Ulkus, secret, massa, nyeri
Perempuan : introitus,
Vagina, serviks, uterius,
Adneksa, nyeri, tumor
REKTUM
Hemoroid, fisura,
Kondikoma, darah, sfingterani _____________________________________________________________
Massa, prostat
NEUROLOGI
Berdiri, gaya jalan, tremor,
Koordinasi, kelemahan,
Flaksid, spastic, paralisis,
Fasikulasi, syaraf karnial,
Reflex fisiologis, reflex
Patologis
BICARA
Disartria, apraxia, afasia
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 L. 2

RESUME DATA DASAR

(Diisi Dengan Temuan Positif)

Oleh dokter : ……………………………………………

N A M A : ……………………………………………………………………. No. RM :

1. KELUHAN UTAMA :

2 ANAMNESIS : (Riwayat penyakit sekarang, Riwyat Penyakit Dahulu, Riwayat Pengobatan,

Riwayat Penyakit Keluarga, Dll)

3. PEMERIKSAAN FISIK :

4. PEMERIKSA TAMBAHAN

A. LABORATORIUM :

B. RADIOLOGI :

C. LAIN – LAIN :

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 L. 3

DAFTAR MASALAH
No Masalah Data Pendukung

8
 L. 4

RENCANA AWAL
Nama Penderita : No. RM .: Th.
Rencana yan akan dilakukan untuk masing – masing masalah ( meliputi rencana untuk diagnose, penatalaksanaan dan edukasi )
No. Masalah Rencana Rencana
Rencana Diagnosis Rencana Edukasi
Terapi Monitoring

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 L. 6

LEMBARAN CATATAN HARIAN DOKTER

TINDAK LANJUT
Nama Penderita : No. RM. : Th.

Tgl. / No. Paraf /

Subyektif Obyektif Assesment Planing
Jam Msl Nama

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