PEMERINTAH KABUPATEN PENAJAM PASER UTARA

RSUD RATU AJI PUTRI BOTUNG

Jln. Provinsi Km. 09 Kel. Nipah-Nipah Kec. Penajam Telp (0542)7211361 Fax (0542) 7211419

ASSESMEN MEDIS Nama : No. RM :

RAWAT JALAN Tgl.Lahir/Umur : Bangsal :

PASIEN UMUM Jenis Kelamin : DPJP :

DAFTAR ALERGI OBAT DAN REAKSI EFEK SAMPING OBAT
Nama Obat Reaksi Tanggal/Tahun
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Anamnesa/Alloanamnesis* dengan : .............................. Hubungan dengan pasien : ..............................

KELUHAN UTAMA :
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PERJALANA N PENYAKIT SEKARANG :

(Lokasi, Onset dan Kronologis, Kualitas, Faktor Memperberat, Faktor Memperingan, Gejala Penyerta)
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RIWAYAT PENYAKIT LAIN

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RIWAYAT PENYAKIT KELUARGA

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RIWAYAT SOSIAL EKONOMI

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Obat-obatan yang dikonsumsi pasien saat ini :

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PEMERIKSAAN FISIK PASIEN TANDA VITAL
Tekanan darah : ..........mmHg Denyut jantung : ..........x/menit Saturasi O2 : .............%
Pernafasan : ..........x/menit Reguler/Irregular : .................... Tipe : ..............
o
Suhu : .......... C
Keadaan Umum : □ Baik □ Tampak baik
□ Sesak □ Pucat □ Lemah □ Kejang □ Lainnya ................................
Gambaran umum lainnya : Nutrisi : ........................................... Oedema : ...........................................
Clubing finger : ........................................... Dehidrasi : ..........................................
Lanjutan : Assesmen Medis Rawat Jalan Pasien Umum
Pucat : ........................................... Jaundice : ...........................................
PEMERIKSAAN FISIK TAMBAHAN
Hal. 1 (Lanjut sebaliknya)
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PEMERIKSAAN PENUNJANG
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DIAGNOSIS KERJA
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TERAPI
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RENCANA TINDAK LANJUT
Rawat Inap Ruang : ………………………………………….. Indikasi : …………………………..
DPJP Rawat Inap : …………………………..
Pengantar Pasien : Ada / Tidak* (Bila tidak, rujuk ke Dinas Sosial)
Rujuk ke : □ RS ………………………………………………. □ Puskesmas
□ Dokter keluarga ………………………….. □ Dokter …………………………………………
□ Homecare
Kontrol Klinik / Homecare di : …………………………………………………….
Tanggal : …………………………………………………….
EDUKASI PASIEN
Edukasi Awal, disampaikan tentang diagnosis, Rencana dan Tujuan Terapi kepada :
□ Pasien
□ Keluarga pasien, nama : ……………………………………………………………………………………………………………………………
□ Tidak dapat member edukasi kepada pasien atau keluarga, Karena ……………………………………………………….

Penajam, …………………………… Jam ……….. WIB

DPJP

( ………………………………. )
Tanda tangan dan nama terang

Hal. 2