PEMERINTAH KABUPATEN PANDEGLANG

DINAS KESEHATAN
UPT PUSKESMAS BANJAR
Alamat :Jl.Cibiuk No.2 Kp.Kadugedong– Telp. (0253) 201005 Banjar
Email : puskesmas.banjar@gmail.com

STATUS PASIEN RUANG TINDKAN/UGD

IDENTITAS PASIEN
Nama :
Alamat :
Usia : No. Register :
Jenis Kelamin : L /P Tanggal Masuk :

Anemnesa Perawat Jam : .......................

Keluhan Utama :
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Anamnesa :
.......................................................................................................................................................................................
...................................................................................................................
Riwayat Penyakit Dahulu :
.....................................................................................................................................................
Riwayat Alergi : □ Tidak □Ada (Jelaskan) .......................................

Keadaan Pra Hospital : GCS : ........................ Tensi Darah : .............mmHg Nadi : ……….......... x/mnt
Pernafasan : …….......x/mnt Suhu Axiler : ………......... C o

Tindakan Pra Hospital :

□ CPR □ O2 □ Infus □ NGT □ Nasopharingeal Tube □ Bidai
□Catheter Urine □ Beban Tekan □ Haecting □ Lain

PEMERIKSAAN FISIK
ORGAN NORMAL TEMUAN
Kepala
Leher
Thorak
Abdomen
Ekstremitas
Genitas

Diagnosis :

Therapi :

Perawat Dokter

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Nama Terang dan Tanda Tangan Nama Terang dan Tanda Tangan