RS PKU Nama : :

Muhammadiyah Tgl : :
Surakarta Lahir/Umur : :
No RM : :
Jenis Kelamin : : Ruang :
ASESMEN MEDIS Tgl Masuk : : Kelas :
RAWAT INAP ANAK DPJP : :
PPJP : :
Diisi oleh Dokter
Tanggal :
I. ANAMNESA
1. Keluhan Utama ....................................................................................................................................
2. Riwayat penyakit ....................................................................................................................................................
sekarang ....................................................................................................................................................
..................................................................................................................
3. Riwayat penyakit dulu ....................................................................................................................................................
....................................................................................................................................................
..................................................................................................................
4. Riwayat penyakit ....................................................................................................................................................
keluarga & pohon ....................................................................................................................................................
keluarga ....................................................................................................................................................
....................................................................................................................................................
.................................................................................................
5. Riwayat kehamilan dan ....................................................................................................................................................
persalinan ....................................................................................................................................................
.................................................................................................................
6. Riwayat makanan ....................................................................................................................................................
..................................................................................................................................
7. Riwayat pertumbuhan ....................................................................................................................................................
dan perkembangan ....................................................................................................................................................
....................................................................................................................................................
.............................................................................................................
8. Riwayat imunisasi ....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
............................................................................................

II. PEMERIKSAAN FISIK

 1. Kesan Umum :......................................................................................................................
2. Tanda vital : T: S: N: RR:
3. Status gizi : BB :
TB :
LK :
4. Kepala :......................................................................................................................
5. Leher :......................................................................................................................
6. Dada :......................................................................................................................
7. Jantung :......................................................................................................................
8. Paru –paru :......................................................................................................................
9. Abdomen :......................................................................................................................
10. Genitalia :......................................................................................................................
11. Extremitas :......................................................................................................................

III. ASSESMEN..........................................................................................................................................................
IV. RENCANA PENGELOLAAN
1. Pemeriksaan penunjang
a. Laboratorium :.....................................................................................................................................
b. Radiologi :.......................................................................................................................................
c. ECO :......................................................................................................................................
d. Lain – lain :......................................................................................................................................

2. Terapi :.................................................................................................................................................................................
.............................................................................................................................................................................................
....................................................................................................................................................................

Tanda tangan DPJP

( )