STATUS KLINIS FISIOTERAPI PEDIATRI

□ Initial Asesment □ Re-Evaluasi □ Discharge

No.MR:
Hari/Tanggal Pemeriksaan : Jam :

I. Identitas Pasien
Nama :
Tempat/Tgl Lahir :
Nama Ayah :
Nama Ibu :
Alamat :

No. Telp Rumah :

No Hp :
Dx. Medis :

II. Pemeriksaan Vital Sign

a. Suhu tubuh :
b. Tekanan darah :
c. Denyut nadi :
d. Pernafasan :

III. Pemeriksaan Fisioterapi

a. Anamnesa :
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b. Kesan awal saat pertama bertemu klien :
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PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

c. Kemampuan sensorik :
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d. Kondisi keseimbangan :
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e. Kemampuan dan ketidak mampuan klien
1) Sesuai dengan umur Kronologis
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2) Terlambat tidak sesuai dengan usia perkembangan
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f. Tonus Otot
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g. Pola Postural ( dari kranial ke kaudal)
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PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

h. Deformitas/ kecacatan :
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i. Pemeriksaan khusus (menggunakan assesment tools
GMFM/ASWORTH/Reflex/Sensori/AIM/EIDP,dll)
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(Tandai bagian tubuh yang bermasalah)

PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

IV. Diagnosis Fisioterapi Berdasarkan ICF-CY
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V. Tujuan Fisioterapi
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VI. Rencana Intervensi Fisioterapi

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PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

VII.Evaluasi
a. Sesaat (setelah fisioterapi):
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b. Berkala (mingguan/ bulanan):
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Jakarta, ................................ 2016

Menyetujui ,
Pembimbing Lahan Mahasiswa yang Menangani,

( ) ( )
NIP: NIM:

PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016