RUMAH SAKIT PERMATA HATI Nama Lengkap:

Jl. Raya Way Jepara Plangkawati II Labuhan Ratu Baru, Tanggal Lahir : L/ P
Lampung Timur – Lampung
Telp. (0725) 640123 / Fax. (0725) 641222 Nomor RM :

ASSESMEN AWAL MATA

Pemeriksaan Tanggal :........../......./........... Jam :...........

1. Assesmen Perawat Nama Perawat : Tanda tangan :

A. Data Subyektif :
Ananmnese : ................................................................................................................................................................
B. Riwayat Penyakit :
......................................................................................................................................................................................
.......................................................................................................................................................................................
C. Data Obyektif :
Keadaan Umum: Baik Sedan Buruk Keadaan Gizi : Bai Cukup Kurang
Tensi : …………………/……………,mm.Hg Nadi :………………….x/mnt Suhu : ………………… C°
Nafas : ……………………………….x/mnt Skala nyeri :……………… BB :……… kg
TB : ................................. Cm Kesadaran / GCS : ........................................................................

2. Assesmen Dokter

A. Data Subyektif
Keluhan Utama : ...................................................................................................................................................................
Riwayat Penyakit Sekarang : .................................................................................................................................................
...............................................................................................................................................................................................
Riwayat Penyakit Dahulu : ....................................................................................................................................................
..............................................................................................................................................................................................
B. Data Objektif
Pemeriksaan Mata luar : .....................................................................................................................................................

Visus
Koreksi

Gerakan Bola
Mata
Lapang Pandang
Koreksi

Kedudukan Bola Mata

Konjungtiva
Kedudukan Bola Mata
Segmen Mata Anterior
Palpebra
 Sklera
Lapang Pandang
Kornea
Lapang Pandang
Bilik
mata
Pupil
Kornea
Kornea
Iris
Kornea
Lensa
Pemeriksaan Mata Dalam Kornea

Reflek
Lain - Lain Fundus
Kornea
TIO
Diagnosa Kerja : KorneaEdukasi :

Terapi :

Verifikasi Edukasi
Mengerti Tidak Mengerti
Penerima Edukasi

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Dokter Pemeriksa Menyetujui, tindakan medis yaitu :

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