STATUS KLINIS PASIEN PROGRAM PROFESI FISIOTERAPI

FAKULTAS ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH SURAKARTA

Nomor Urut : ____/_____/_____

IDENTITAS MAHASISWA
Nama Mahasiswa : ___________________________________
No Induk Mahasiswa : ___________________________________
Tempat Praktek : ___________________________________
Nama Pembimbing : ___________________________________
Tanggal Pembuatan Laporan : ___________________________________
Kondisi/Kasus : ___________________________________

I. KETERANGAN UMUM PENDERITA

Identitas Pasien
No RM : ............................................................................
Nama : ............................................................................
Umur : ............................................................................
Jenis Kelamin : L / P
Alamat : ............................................................................
Agama : ............................................................................
Pekerjaan : ............................................................................

II. DATA MEDIS RUMAH SAKIT

(Hasil : Foto Rontgen, uji Laboratorium, CT-Scan, MRI, EMG, EKG, EEG, dll
yang terkait dengan permasalahan fisioterapi)
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III. SEGI FISIOTERAPI
A. PEMERIKSAAN SUBJEKTIF
1. Body Chart

2. Keluhan Utama dan Riwayat Penyakit Sekarang

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3. Riwayat Keluarga dan Status Sosial

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4. Riwayat Penyakit Dahulu

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B. PEMERIKSAAN OBJEKTIF
1. Pemeriksaan Vital Sign :
BP : _______mm/Hg HR : _______ x/Sec BB : _______Kg
RR : _______x/Sec SH : _______Celcius TB : _______ cm

2. Inspeksi :
Inspeksi Statis :
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Inspeksi Dinamis
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3. Palpasi
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4. Auskultasi
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5. Perkusi

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6. Pemeriksaan Gerak Dasar :
a. Gerak Aktif

Bidang Gerak ROM Nyeri Bidang Gerak ROM Nyeri

Shoulder Hip
Fleksi Fleksi
Ektensi Ekstensi
Abduksi Abduksi
Adduksi Adduksi
Horzl Abd Eksternal Rotasi
Horzl Add Internal Rotasi
Ekstrl Rotasi Knee
Intrl Rotasi Fleksi
Elbow Ekstensi
Fleksi Ankle
Ekstensi Dorsi Fleksi
Wrist Plantar Fleksi
Fleksi Inversi
Ekstensi Eversi
Radial deviasi
Ulna deviasi

b. Gerak Pasif
Bidang Gerak ROM Nyeri End Bidang Gerak ROM Nyeri End
Feel Feel
Shoulder Hip
Fleksi Fleksi
Ektensi Ekstensi
Abduksi Abduksi
Adduksi Adduksi
Horzl Abd Eksternal Rotasi
Horzl Add Internal Rotasi
Ekstrl Rotasi Knee
Intrl Rotasi Fleksi
Elbow Ekstensi
Fleksi Ankle
Ekstensi Dorsi Fleksi
Wrist Plantar Fleksi
Fleksi Inversi
Ekstensi Eversi
Radial deviasi
Ulna deviasi
 c. Gerak Isometrik Melawan Tahanan
Bidang Gerak Kontraksi Nyeri Bidang Gerak Kontraksi Nyeri
Shoulder Hip
Fleksi Fleksi
Ektensi Ekstensi
Abduksi Abduksi
Adduksi Adduksi
Horzl Abd Eksternal Rotasi
Horzl Add Internal Rotasi
Ekstrl Rotasi Knee
Intrl Rotasi Fleksi
Elbow Ekstensi
Fleksi Ankle
Ekstensi Dorsi Fleksi
Wrist Plantar Fleksi
Fleksi Inversi
Ekstensi Eversi
Radial deviasi
Ulna deviasi

7. Pemeriksaan Nyeri :
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8. Test Kognitif, Intra Personal, dan Interpersonal

Kognitif :
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Intra Personal :
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Interpersonal :
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 9. Test Kemampuan Fungsional dan Lingkungan Aktifitas
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C. PEMERIKSAAN FISIK
1. LGS

Bidang Gerak Nilai LGS Bidang Gerak Nilai LGS

Shoulder Hip

Elbow Knee

Wrist Ankle

2. MMT

Bidang Gerak Nilai MMT Bidang Gerak Nilai MMT

Shoulder Hip
Fleksi Fleksi
Ektensi Ekstensi
Abduksi Abduksi
Adduksi Adduksi
Horzl Abd Eksternal Rotasi
Horzl Add Internal Rotasi
Ekstrl Rotasi Knee
Intrl Rotasi Fleksi
Elbow Ekstensi
Fleksi Ankle
Ekstensi Dorsi Fleksi
Wrist Plantar Fleksi
Fleksi Inversi
Ekstensi Eversi
Radial deviasi
Ulna deviasi
D. PEMERIKSAAN KHUSUS
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E. DIAGNOSIS FISIOTERAPI
a. Impairment
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b. Functional Limitation
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c. Participation Restriction
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F. PROGRAM FISIOTERAPI
Jangka Pendek :
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Jangka Panjang
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G. INTERVENSI FISIOTERAPI
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H. RENCANA EVALUASI
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I. UNDERLYING PROCESS
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J. PROGNOSIS
Qua at Vitam : _______________________
Qua at Sanam : _______________________
Qua at Cosmeticam : _______________________

K. EVALUASI TINDAK LANJUT

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L. HASIL TERAPI AKHIR

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_________________, - - 2017

CE/Preceptor

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