Anda di halaman 1dari 5

MR.3A-I/B.

NON TRAUMA/RI/2015

RSK. Dr. TadjuddinChalid Makassar


Jl. Pajjaiang/Paccerakkang No. 67 Daya Makassar
Telp. (0411) 512902, Faksimile : (0411) 511011
PENGKAJIAN AWAL RAWAT INAP MEDIS
BEDAH - NON TRAUMA

Ruangan : Tanggal : Jam :

No. RekamMedik : .....................................................................................................................................................................................


NamaLengkap : .....................................................................................................................................................................................
JenisKelamin : .....................................................................................................................................................................................
TanggalLahir : .....................................................................................................................................................................................
Alamat : .....................................................................................................................................................................................
Rujukan : Ya, dari, RS ....................... Puskesmas........................ Praktek ............................ Lainnya ...............................
Diagnosa Rujukan ...............................................................................................................................................................................
Tidak Datang Sendiri Diantar …………………………………………………..….

Dokter yang Memeriksa : ......................................................... Supervisor jaga : ............................................................................


ANAMNESA Tanggal : Jam :
1. Keluhan Utama: ......................................................................................................................................................................................
2. Riwayat Penyakit Sekarang: ....................................................................................................................................................................
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MR.3A-II/B.NON TRAUMA/RI/2015

RSK. Dr. TadjuddinChalid Makassar


Jl. Pajjaiang/Paccerakkang No. 67 Daya Makassar
Telp. (0411) 512902, Faksimile : (0411) 511011
PENGKAJIAN AWAL RAWAT INAP MEDIS
BEDAH - NON TRAUMA

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2/5
MR.3A-III/B.NON TRAUMA/RI/2015

RSK. Dr. TadjuddinChalid Makassar


Jl. Pajjaiang/Paccerakkang No. 67 Daya Makassar
Telp. (0411) 512902, Faksimile : (0411) 511011
PENGKAJIAN AWAL RAWAT INAP MEDIS
BEDAH - NON TRAUMA

NamaPasien :No. RekamMedis:Tgl. Lahir :Ruangan :

3. Riwayat Penyakit dahulu:


Hipertensi DM PJK Asma Stroke
Liver Ginjal TB Paru Lain-lain ………………………………………………
Pernah dirawat Tidak Ya,Kapan ………… Di mana …………………………… Diagnosis ……………………………
4. Riwayat Pengobatan (termasuk obat yang sedang dikonsumsi) :
Nama Obat Dosis Waktu Penggunaan
1. ………………………………………. ………………….…………………. ………………………………………
2. ………………………………………. …………………………………….. ………………………………………
3. …………………………………........ ………………….…......………….. ………………………………………
4. …………………………………….… ………………………………..…… .………………………………………
5. Riwayat Penyakit Keluarga
Hipertensi Kencing Manis Jantung Asma Lainnya …………………………………………………

PENILAIAN NYERI
Nyeri : Tidak Ya: Lokasi: …………….……. Intensitas ……Skor : …… (Metode VAS/BPS/NIPS/FLACC)

Jenis : Akut Kronis

Alergi :  Tidak Ada Ya……………................................................................

TANDA-TANDA VITAL
KeadaanUmum: Baik Sedang Lemah Jelek, Gizi: Baik Kurang Buruk
GCS: E….... M….... V….…. Tindakan Resusitasi: Ya Tidak
BB : ………… Kg TB:……… cm
Tek. Darah: …………. mmHg, Nadi: …………. x/mnt
Respirasi: …….. x/mnt, SuhuAxila/Rektal: ………… OC/……………. OC

PEMERIKSAAN FISIS
Mata :Anemis: Tidak Ada,Ikterus: Tidak Ada,Pupil : anisokor Isokor, diameter ........../.......... mm,
UdemPalpebrae : Tidak Ada
THT : Tonsil:…………………, Faring: ………………………, Lidah: ………………………., Bibir:…………......……......................
Leher : JVP: ………………….., Pembesaran Kelenjar Limfe: Tidak Ada, ...........................................Kaku kuduk : Tidak Ada
Thoraks : Simetris Asimetris: ...................................................................................................................................
Cor : S1/S2 ……………………………. Reguler Ireguler, Murmur .......................................................................
Lain-lain :..............................................................................................................................................................................
Pulmo: Suara Nafas: ......................................, Ronchi: Tidak Ada ....................................................................
Wheezing : Tidak Ada, ............................................................................................................................
Abdomen : Distended : Tidak Ada, Meteorismus: Tidak Ada
Peristaltik : Normal Meningkat menurun Tidak ada, Asites: Tidak Ada
Nyeri Tekan: Tidak Ada, Lokasi: ............................................................................................................
Hepar : .........................................................., Lien : ..........................................................................................
Extremitas : Hangat Dingin Udem : Tidak Ada, ..................................................................
Lain-Lain: ..............................................................................................................................................................

3/5
MR.3A-IV/B.NON TRAUMA/RI/2015

RSK. Dr. TadjuddinChalid Makassar


Jl. Pajjaiang/Paccerakkang No. 67 Daya Makassar
Telp. (0411) 512902, Faksimile : (0411) 511011
PENGKAJIAN AWAL RAWAT INAP MEDIS
BEDAH - NON TRAUMA

STATUS LOKALIS

HASIL PEMERIKSAAN PENUNJANG DIAGNOSA

1. ....................................................................................................
2. ....................................................................................................
3. ....................................................................................................
4. ....................................................................................................
5. ....................................................................................................
TERAPI

RENCANA KERJA

4/5
MR.3A-V/B.NON TRAUMA/RI/2015

RSK. Dr. TadjuddinChalid Makassar


Jl. Pajjaiang/Paccerakkang No. 67 Daya Makassar
Telp. (0411) 512902, Faksimile : (0411) 511011
PENGKAJIAN AWAL RAWAT INAP MEDIS
BEDAH - NON TRAUMA

NamaPasien :No. RekamMedis :Tgl. Lahir :Ruangan :

HASIL PEMBEDAHAN

DIAGNOSA AKHIR

DISPOSISI
Hidup: Boleh pulang Jam Keluar: ……………wita Tanggal : ……………………………….
Kontrol polkinik: Tidak Ya,……………………….Tanggal: ……………..,………………
Dirawat diruang: Intensif/ ICU

Ruang lain: …………………………. Kelas …………..


Mati:  Death on Arrival Setelah resusitasi Jam ………………….. wita Tanggal : ……………………………………………….
 Penyebab kematian : ……………………………………………….........
REKOMENDASI (SARAN ) CATATAN PENTING

Yang Melakukan Pengkajian


Tanggal / Jam : Tanda tangan dokter
Nama Dokter :

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