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FORMAT STATUS KLINIK FISIOTERAPI

AKADEMI FISIOTERAPI
UNIVERSITAS KRISTEN INDONESIA

Nomor MR: ………………

Nama Mahasiswa : ………………………………………


NIM : ………………………………………
Tempat : ……………………………………....
Pembimbing : ……………………………………....

Tanggal Pembuatan Laporan : ………………………………

A. DATA-DATA MEDIS RUMAH SAKIT


I. Diagnosa Medis : …………………………….............................................
II. Catatan Klinis
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B. SEGI FISIOTERAPI
I. ASESMEN FISIOTERAPI
a. Anamnesis (Auto/Hetero)
1. Identitas
Nama : ………………………………….
Umur : ………………………………….
Jenis Kelamin : L/P
Agama : ………………………………….
Status Perkawinan : ………………………………….
Pekerjaan : ………………………………….
Alamat : ………………………………….

2. Riwayat Penyakit
2.1.Keluhan Utama…………………………………………………
2.2. Riwayat Penyakit Sekarang
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FORMAT STATUS KLINIK FISIOTERAPI
AKADEMI FISIOTERAPI
UNIVERSITAS KRISTEN INDONESIA

2.3. Riwayat Penyakit Dahulu


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2.4. Riwayat Pribadi


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2.5. Riwayat Keluarga


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b. Pemeriksaan Fisik
1. Tanda Vital dan Keadaan Umum
1.1. Tekanan darah : …………………………….
1.2. Denyut nadi : …………………………….
1.3. Pernapasan : …………………………….
1.4. Temperatur : …………………………….
1.5. Tinggi badan : …………………………….
1.6. Berat badan : …………………………….
1.7. Tingkat kesadaran : ………………………….....
2. Inspeksi
2.1. Inspeksi statis
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2.2. Inspeksi dinamis


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3. Palpasi
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FORMAT STATUS KLINIK FISIOTERAPI
AKADEMI FISIOTERAPI
UNIVERSITAS KRISTEN INDONESIA

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4. Perkusi
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5. Auskultasi
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6. Pemeriksaan Fungsi Gerak Dasar


5.1. Gerak Aktif
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5.2. Gerak Pasif


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FORMAT STATUS KLINIK FISIOTERAPI
AKADEMI FISIOTERAPI
UNIVERSITAS KRISTEN INDONESIA

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5.3. Gerak Isometrik Melawan Tahanan


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7. Pemeriksaan Khusus
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FORMAT STATUS KLINIK FISIOTERAPI
AKADEMI FISIOTERAPI
UNIVERSITAS KRISTEN INDONESIA

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8. Pemeriksaan Tambahan/Pendukung
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c. Pemeriksaan Kemampuan Kognitif, Intrapersonal dan Interpersonal


1. Pemeriksaan Kemampuan Kognitif
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2. Pemeriksaan Kemampuan Intrapersonal


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3. Pemeriksaan Kemampuan Interpersonal


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d. Pemeriksaan Kemampuan Fungsional dan Lingkungan Aktivitas


1. Kemampuan Fungsional Dasar
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2. Aktivitas Fungsional
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3. Lingkungan Aktivitas
FORMAT STATUS KLINIK FISIOTERAPI
AKADEMI FISIOTERAPI
UNIVERSITAS KRISTEN INDONESIA

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e. Problematik Fisioterapi
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II. DIAGNOSA FISIOTERAPI
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III. RENCANA PROGRAM FISIOTERAPI


a. Tujuan Jangka Pendek
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b. Tujuan Jangka Panjang


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c. Rencana Intervensi Fisioterapi


1. Modalitas Alternatif
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FORMAT STATUS KLINIK FISIOTERAPI
AKADEMI FISIOTERAPI
UNIVERSITAS KRISTEN INDONESIA

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2. Modalitas Terpilih
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3. Modalitas Yang Dilaksanakan


Alasan perubahan modalitas
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d. Rencana Evaluasi Fisioterapi


1. Evaluasi Sesaat
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FORMAT STATUS KLINIK FISIOTERAPI
AKADEMI FISIOTERAPI
UNIVERSITAS KRISTEN INDONESIA

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2. Evaluasi Periodik
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3. Evaluasi Kumulatif
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e. Prognosis
Quo ad functionam :
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IV. PELAKSANAAN PROGRAM FISIOTERAPI


Implementasi dan modifikasi pelaksanaan fisioterapi
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FORMAT STATUS KLINIK FISIOTERAPI
AKADEMI FISIOTERAPI
UNIVERSITAS KRISTEN INDONESIA

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V. (RE)EVALUASI FISIOTERAPI
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VI. MODALITAS MODIFIKASI


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VII. HOME PROGRAM


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FORMAT STATUS KLINIK FISIOTERAPI
AKADEMI FISIOTERAPI
UNIVERSITAS KRISTEN INDONESIA

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