PEMERINTAH PROVINSI DAERAH KHUSUS IBUKOTA JAKARTA

DINAS KESEHATAN
RUMAH SAKIT UMUM DAERAH KRAMAT JATI
Jln. Raya Inpres No. 48 Telp./Fax. : 87791352 / 87793604
E-mail : rsukramatjati@gmail.com
JAKARTA TIMUR

Nama :
ASESMEN AWAL MEDIS No. RM :
RAWAT INAP Tgl.Lahir / umur :
(Dilengkapi dalam 24 jam pertama pasien masuk ruang rawat) Jenis Kelamin : □ Laki-laki □ Perempuan

(Diisi atau tempelkan stiker jika ada)

Tanggal : Jam :

Agama : Gol. Darah : Pendidikan :

Sumber data :  Pasien  Keluarga  Lainnya ……………………

DATA MEDIS (diisi oleh dokter)

1. Keluhan Utama

RIWAYAT PENYAKIT
a. Riwayat Penyakit Sekarang :

b. Riwayat Penyakit Dahulu :

c. Riwayat Penyakit Dalam Keluarga :

d. Riwayat Pekerjaan ( apakah berhubungan dengan zat – zat berbahaya ) :

2. PEMERIKSAAN UMUM / GENERAL EXAMINATION

 Kesadaran : ● Keadaan Umum :  Baik  Sedang  Buruk
 Tekanan Darah : mmHg ● Keadaan Gizi :  Baik  Sedang  Buruk
 Nadi : x/mnt ● BB : kg
 Suhu : 0
C ● TB : cm
 Pernapasan : x/mnt
 SpO2 : ● Skor Nyeri :

a. Kulit : ...................................................................................................................................................
b. Kepala :....................................................................................................................................................
c. Rambut : ...................................................................................................................................................
d. Mata : ...................................................................................................................................................
e. THT : ...................................................................................................................................................
f. Gigi & Mulut : ...................................................................................................................................................
g. Leher : ...................................................................................................................................................
h. Dada : ...................................................................................................................................................
- Paru : Inspeksi : ..................................................................................................................................
Palpasi : ..................................................................................................................................
 PEMERINTAH PROVINSI DAERAH KHUSUS IBUKOTA JAKARTA
DINAS KESEHATAN
RUMAH SAKIT UMUM DAERAH KRAMAT JATI
Jln. Raya Inpres No. 48 Telp./Fax. : 87791352 / 87793604
E-mail : rsukramatjati@gmail.com
JAKARTA TIMUR
Perkusi : ...................................................................................................................................
Auskultasi : ................................................................................................................................

- Jantung : Inspeksi : ..................................................................................................................................

Palpasi : ..................................................................................................................................
Perkusi : ...................................................................................................................................
Auskultasi : ................................................................................................................................
i. Abdomen : ...................................................................................................................................................
j. Genetalia : ...................................................................................................................................................
k. Anus : (Colok Dubur atas indikasi)
l. Anggota gerak : .................................................................................................................................................
m. Kelenjar getah bening : ................................................................................................................................

3. PEMERIKSAAN PENUNJANG PRE RAWAT INAP

...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................

4. DIAGNOSA KERJA / DIAGNOSA BANDING :................................................................................................

...................................................................................................................................................................................
5. PENGOBATAN :
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................

6. DIET : ......................................................................................................................................................................

7. PROGNOSA : ..........................................................................................................................................................

8. PERAWATAN YANG DIBERIKAN:

 Paliatif  Kuratif  Preventif  Rehabilitatif

Tanggal…………………..
Nama dan Tanda Tangan Jam…….……
Dokter Penanggung Jawab Dokter yang memeriksa

(……………….....………….)
(………………….....……….)
Nama dan Tanda Tangan
Pasien / Keluarga

(………………….....………….)