RUMAH SAKIT PERMATA HATI Nama Lengkap:

Jl. Raya Way Jepara Plangkawati II Labuhan Ratu Baru,

Tanggal Lahir : L/ P
Data S ubyektifLampung : Timur – Lampung
AnanmneseTelp. Nomor RM :
: ................................................................................................................................................................
(0725) 640123 / Fax. (0725) 641222
Riwayat ASSESMEN AWAL MATA
Penyakit : ...........................................................................................................................................................................
Pemeriksaan
........... Tanggal :........../......./........... Jam :...........
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Assesmen Perawat Nama Perawat : Tanda tangan :
Data Obyektif :
Keadaan Umum:  Baik  Sedang  B uruk Keadaan Gizi :  Baik  Cukup  Kurang
Tensi : …………………/……………,mm.Hg Nadi :………………….x/mnt Suhu : ………………… C°
Nafas : ……………………………….x/mnt Skala nyeri :……………… BB :……… kg
TB : ................................. Cm Kesadaran / GCS : ........................................................................

A. Data Subyektif

Keluhan Utama : ...................................................................................................................................................................

Riwayat Penyakit Sekarang : .................................................................................................................................................

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2. Assesmen Dokter
Riwayat Penyakit Dahulu : ....................................................................................................................................................

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B. Data Objektif

Pemeriksaan Mata luar : .....................................................................................................................................................

Visus
Koreksi

Gerakan Bola Mata

Lapang Pandang

Kedudukan Bola Mata

Konjungtiva

Palpebra
Segmen Mata Anterior Sklera
Kornea
Diagnosa Kerja : Bilik mata
Edukasi :
Pupil
Iris
Terapi :
Lensa
Pemeriksaan Mata Dalam

Reflek Fundus
Lain - Lain

TIO
Verifikasi Edukasi

Mengerti Tidak Mengerti

Penerima Edukasi

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Dokter Pemeriksa Menyetujui, tindakan medis yaitu :

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