RSIA HARAPAN BUNDA NAMA : , L/P

Jl. Tukad Unda No. 1 Renon Denpasar – Bali

Telp. : (0361) 265533, 265534, Fax, : (0361) 265532
UMUR/tgl lahir : hr/bln/thn

No. RM Pasien:
ASESMEN MEDIS NON TRAUMA INSTALASI GAWAT DARURAT

TGL ;………………………………………………………………………………………………, JAM ;……………………………………………………………………………………………………..

Rujukan :  Ya, dari  RS .....................................  Puskesmas .......................................
 Dr .....................................  Lainnya ...........................................
Dx. Rujukan ..............................................................................................................
 Tidak,  Datang sendiri  Diantar oleh ....................................
Nama keluarga yang bisa dihubungi : .................................................. Telp: ......................................
Alamat : ............................................................................................Pekerjaan:…………….
Transportasi waktu datang :  Ambulans RSIA Harapan Bunda Denpasar  Ambulans lain ........... . Kend.
Lainnya .................
ALERGI TERHADAP :
Tanda Tangan Dokter
Dokter yang memeriksa : ..................................................
Supervisor Jaga : ..................................................

ANAMNESA:
1. Keluhan Utama: Skala Nyeri

2. Riwayat Penyakit Sekarang:

3. Riwayat Pengobatan:
 Antibiotik: ..............................  Analgetik/Antipiretik: ..............................  Antialergi: ...................................
 Steroid:...................................  Vitamin: ....................................................  Antimuntah: ..............................

4. Riwayat Penyakit Dahulu:

 Hipertensi  Kencing Manis  Jantung  Asma  Lainnya ...........................................

5. Riwayat Penyakit Keluarga:

 Hipertensi  Kencing Manis  Jantung  Asma  Lainnya ...........................................

6. Riwayat Sosial:
 Merokok  Minum alkohol  Lainnya ......................................................................................................

TANDA-TANDA VITAL

Keadaan umum :  Baik  Sedang  Lemah  Jelek,

Gizi:  Baik  Sedang  Kurang  Buruk
GCS: E .... V .... M .... Tindakan resusitasi:  Ya, .............................  Tidak
Tensi: ................. mmHg Nadi: ............ x/mnt
Respirasi: ............ x/mnt Saturasi O2: .......... % pada:  Suhu ruangan  Nasal Canule  NRB  Lainnya ..............
Suhu Axilla/rectal: ..............ºC / ..............ºC Berat Badan: ............. Kg

PEMERIKSAAN FISIK
Kepala  Normal  Abnormal .........................................................................................................................
Mata  Normal  Abnormal .........................................................................................................................
THT  Normal  Abnormal .........................................................................................................................
Leher  Normal  Abnormal .........................................................................................................................
Dada  Normal  Abnormal .........................................................................................................................
 Jantung  Normal  Abnormal .........................................................................................................................
 Paru  Normal  Abnormal .........................................................................................................................
Perut  Normal  Abnormal .........................................................................................................................
 Hepar  Normal  Abnormal .........................................................................................................................
 Lien  Normal  Abnormal .........................................................................................................................
Punggung  Normal  Abnormal .........................................................................................................................
Genital  Normal  Abnormal .........................................................................................................................
Ekstremitas  Normal  Abnormal .........................................................................................................................
Rectal Toucher  Normal  Abnormal .........................................................................................................................

STATUS LOKALIS SKEMA

RENCANA KERJA HASIL PEMERIKSAAN PENUNJANG

DIAGNOSA ICD-X TERAPI

HASIL PEMBEDAHAN

DIAGNOSA AKHIR

DISPOSISI
 Hidup:  Boleh pulang, Jam Keluar: ................ Wita Tanggal : .................................
Kontrol Poliklinik  Ya, ................................. Tanggal : .................................,  Tidak
 Dirawat di ruang:  Intensif  MS/Ratna  Ruang lain : .............................. Kelas ..................
 Mati:  Death on Arrival
 Setelah resusitasi Jam ............................. Wita Tanggal : .................................
Penyebab kematian : ..............................................................................................................................................
REKOMENDASI (SARAN) CATATAN PENTING