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MR.

3A-I/OBGYN/RI/2015

RSK. Dr. TadjuddinChalid Makassar


Jl. Pajjaiang/Paccerakkang No 67 Daya Makassar
Telp. (0411) 512902, Faksimile : (0411) 511011

PENGKAJIAN AWAL RAWAT INAP MEDIS


OBSTETRI DAN GINEKOLOGI

Ruangan : Tgl : Jam :

No. RekamMedis : .....................................................................................................................................................................................


NamaLengkap : .............................................................................................................................................L / P
TanggalLahir : .....................................................................................................................................................................................
Rujukan : Ya, dari, RS ....................... Puskesmas ........................ Dr. .............................. Lainnya.............................
Diagnosa Rujukan .............................................................................................................................................................................
Tidak Datang Sendiri Diantar …………………………………………………..….

RiwayatAlergi : Tidak Ada Ada, Sebutkan 1. …………………………………………………………….………………………


2. …………………………………………………………….…………..…………
3. …………………………………………………………….………..……………

Dokter Yang Memeriksa : ……………………………. Supervisor Jaga : …………………………….

ANAMNESA

1. KeluhanSaat ini : ......................................................................................................................................................................................


: ..................................................................................................................................................................................................................
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2. Kehamilan : Gravida :………………………………Para:………………………….Abortus:……………………………………

RiwayatObstetri Tanggal : Oleh :


Gravid ..............Anak aterm Prematur Abortus ...................S.C ............................AnakHidup .......................................
Tempat Anak
Jenis
No persalinan- Tahun Kehamilan Penyulit Nifas Jenis Berat
Persalinan Keadaan
Penolong Kelamin Badan
1
2
3
4
5
6
7
8

3. Riwayat Penyakit dahulu / Faktor Resiko :

Hipertensi DM PJK Asma Stroke Liver Ginjal TB Paru Rokok MinumAlkohol


Lain-lain ………………

4. Riwayat operasi : Tidak Ya, 1) .......................................................... 2) .................................................................................

5. Keluarga berencana : Tidak Ya, cara : .................................................... Sejak : ...................................................................

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MR.3A-II/OBGYN/RI/2015

RSK. Dr. TadjuddinChalid Makassar


Jl. Pajjaiang/Paccerakkang No 67 Daya Makassar
Telp. (0411) 512902, Faksimile : (0411) 511011

PENGKAJIAN AWAL RAWAT INAP MEDIS


OBSTETRI DAN GINEKOLOGI

6. Riwayat Pengobatan (Termasuk obat yang sedang dikonsumsi) :


Nama Obat Dosis Waktu Penggunaan
1. ………………………………………. ………………….…………………. ………………………………………
2. ………………………………………. …………………………………….. ………………………………………
3. ……………………………….…........ ………………….…......….……….. ………………………………………
4. ……………………………….…….… ………………………………...…… .………………………………………

PENILAIAN NYERI

Nyeri : Tidak Ya: Lokasi: …………….……. Intensitas (0-10) ……..…

Jenis : Akut Kronis


Skor : ……….… (Metode VAS/BPS/NIPS/FLACC)

PEMERIKSAAN FISIK
1. Tanda-tanda vital
Kesadaran: Kompos Mentis Apatis Stupor Coma Sulitdinilai
GCS: E ….. M…..V Tindakan Resusitasi :  Ya Tidak
Tensi: ……..... mmHgSuhu ……… OC Nadi: ……... x/mntRespirasi: ….. x/mnt type …….....……..
BeratBadan: ……….. kgTinggiBadan: ……….. cm

2. PemeriksaanFisis:
Mata: Anemis : Tidak Ya, Ikterus : Tidak Ya. Pupil : Isokor Anisokor Ukuran : …………. mm
THT: Tonsil ………….........., Faring………….....…....,  Lidah …………........, Bibir ……………………………,
Leher: JVP ................................., PembesaranKelenjar Tidak Ya, ……………………………..
Thoraks:  Simetris Asimetris................................Cor S1/S2…………….. Reguler Ireguler, Murmur ……....................
Pulmo: Suara nafas …………………………… Ronchi: Tidak Ya, ………………..Wheezing : Tidak Ya……………….........
Abdomen : Hepar ……………………………............................ Lien ……………………………………….....................................................
Extremitas : Hangat/Dingin:…..………………….. Udema : ……………………………….

DIAGNOSA TERAPI

USUL PEMERIKSAAN PENUNJANG DISPOSISI


Boleh pulang Jam Keluar : ………. WitaTanggal: ….
Kontrol Poliklinik Ya…………… Tanggal : ……..…
Tidak
Dirawat di ruang: 

Direview oleh dokter yang merawat di Rawat Inap


Makassar, Tgl ………………………

Tanda Tangan dan Nama Dokter

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MR.3A-III/OBGYN/RI/2015

RSK. Dr. TadjuddinChalid Makassar


Jl. Pajjaiang/Paccerakkang No 67 Daya Makassar
Telp. (0411) 512902, Faksimile : (0411) 511011

PENGKAJIAN AWAL RAWAT INAP MEDIS


OBSTETRI DAN GINEKOLOGI

Persalinan Nama : TanggalLahir: NO. RM :

Tanggal masuk : ................................... Jam ............... PEMERIKSAAN LUAR OLEH : .............................


Ibu Masuk karena : ........................................................... Fundus Uteri : ...........................................................
HIS sejak : ........................................................... Situs anal : .................................................................
Pelepasan lendir/darah : ........................................................... Posisi punggung : ......................................................

Ketuban pecah : Belum Pecah Bagian paling depan : ................................................


Tanda vital : T : ........./........... Nadi : .................. D.D.A : ......................................................................

Suhu : ........... Pernapasan : ............ Tunggal Gemelli


Udem : Tidak Ya, ................. Gerakan Anak : Tidakada Ada
TANGGAL DAN JAM KALA PEMBUKAAN Jam : PIMPINAN DAN TERAPI

KALA PENGELUARAN Jam :

KALA URI Jam :

Perdarahan : ................. cc, Sebab : ............................................


Plasenta : ......................................................................................
.......................................................................................
TaliPusat : ....................................................................................
.....................................................................................
KALA IV (SAMPAI 2 JAM POSTPARTUM)

Perdarahan : ............... cc . Jumlah seluruhnya ...........................


Robekan : .....................................................................................
Kontraksi Uterus : ....................Tinggi fundus : ............................
Keadaan umum : ..........................................................................
T : ............................ N : ............................
RR : ......................... S : ............................
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