UNIVERSITAS PEKALONGAN

No Reg. Pasien
FAKULTAS ILMU KESEHATAN
PROGRAM STUDI DIPLOMA III _____________
FISIOTERAPI

LAPORAN STATUS KLINIK

NAMA MAHASISWA : _________________________________________

NPM : ________________________________________
TEMPAT PRAKTEK : _________________________________________
PEMBIMBING : _________________________________________

SEMESTER / T.AJARAN : _________________________________________

Tanggal Pembuatan Laporan : _________________________________________

Kondisi / Kasus : FT A / FT B / FT C / FT D / FT E

I. KETERANGAN UMUM PENDERITA

NAMA : ____________________________________
UMUR : ____________________________________
JENISKELAMIN : ____________________________________

AGAMA : ____________________________________
PEKERJAAN : ____________________________________
ALAMAT : ____________________________________

II. DATA-DATA MEDIS RUMAH SAKIT

A. DIAGNOSIS MEDIS:

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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
B. CATATAN KLINIS :
1. Riwayat Tindakan Medis

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2. Medikamentosa

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3. Data Pendukung
a. Hasil Laboratorium

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b. Foto Rongten

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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
 c. Dan Lain-lain
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C. TERAPI UMUM (GENERAL TREATMENT)

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D. RUJUKAN FISIOTERAPI DARI DOKTER (asal rujukan dan isi

rujukan)
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III. SEGI FISIOTERAPI

TANGGAL :________________________________
A. PEMERIKSAAN SUBYEKTIF (AUTO/HETERO)
1. KELUHAN UTAMA:
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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
 2. LOKASI KELUHAN (Menunjukkan tempat / lokasi keluhan)

Keterangan :_____________________________________________
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3. RIWAYAT PENYAKIT SEKARANG:

(Berupa perjalanan penyakit dan riwayat pengobatan)

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4. RIWAYAT PENYAKIT DAHULU:

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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
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5. RIWAYAT PENYAKIT PENYERTA :

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6. RIWAYAT PRIBADI DAN STATUS SOSIAL :
(Hobby, lingkungan kerja, tempat tinggal, aktivitas rekreasi dan
diwaktu senggang, aktivitas sosial)

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7. RIWAYAT KELUARGA:

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8. ANAMNESIS SISTEM :
a) Kepala dan Leher :
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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
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b) Kardiovaskuler :

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c) Respirasi
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d) Gastrointestinalis :
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e) Urogenitalis :
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f) Muskuloskeletal :
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g) Nervorum :
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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
B. PEMERIKSAAN OBYEKTIF
1. PEMERIKSAAN TANDA VITAL
a. Tekanan darah : ______________________
b. Denyut Nadi : ______________________
c. Pernapasan : ______________________
d. Temperatur : ______________________
e. Tinggi Badan : ______________________

f. Berat Badan : ______________________

2. INSPEKSI
a. Statis :
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b. Dinamis
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3. PALPASI :
(Spasme, nyeri tekan dimana, tonus otot, oedema, suhu, dll)
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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
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4. PERKUSI :

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5. AUSKULTASI :

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6. GERAK DASAR
1) Gerak Aktif (nyeri, LGS, kekuatan otot, koordinasi gerakan)
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2) Gerak Pasif (LGS, end feel, provokasi nyeri, kelenturan otot,
pola kapsuler)
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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
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3) Gerak Isometrik Melawan Tahanan (Provokasi nyeri, kekuatan
otot)
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7. TES KOGNITIF, INTRAPERSONAL DANINTERPERSONAL

a. Tes Kognitif
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b. Intrapersonal
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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
 c. Interpersonal

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8. KEMAMPUAN FUNGSIONAL DAN LINGKUNGAN AKTIVITAS
a. Kemampuan Fungsioanl Dasar :

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b. Aktivitas Fungsional :

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c. Lingkungan Aktivitas

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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
9. Pemeriksaan Nyeri

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10. Pemeriksaan Kekuatan Otot (MMT)

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11. Pemeriksaan ROM

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12. Pemeriksaan Antopometri

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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
13. Tes dan Pengukuran Perawatan diri Penatalaksaan Rumah Tangga

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14. Pemeriksaan Spesifik Test

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C. DIAGNOSIS FISIOTERAPI
(Menentukan diagnosa gerak dan fungsi melalui interprestasi, analisa
dan sintesis hasil pemeriksaan serta pengukuran pasien / klien).

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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
 1. IMPAIRMENT

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2. DISABILITY

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3. FUNGTIONAL LIMITATION
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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
D. PROGRAM/RENCANA FISIOTERAPI
1. TUJUAN FISIOTERAPI :
a. Tujuan Jangka Pendek

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b. Tujuan Jangka Panjang

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2. TINDAKAN FISIOTERAPI
Teknologi Fisioterapi:
1) Teknologi Alternatif

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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
 2) Teknologi Yang Dilaksanakan
(jelaskan argumen/alasan mengapa ini yang dilaksanakan)

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3. EDUKASI DAN HOME PROGRAM

a. EDUKASI:

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a. HOME PROGRAM

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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
 4. RENCANA EVALUASI
(Sesuai dengan interprestasi data fisioterapi)

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E. PROGNOSIS FISIOTERAPI (Menetapkan prognosis gerak dan fungsi
melaui interprestasi, analisis dan sintesis pemeriksaan dan pengukuran
pasien/klien)

Quo ad vitam :____________________________________

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Quo ad cosmeticam :____________________________________

F. PENATALAKSANAAN FISIOTERAPI :
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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
. G. E V A L U A S I:
(Setelah Tindakan Terapi/per tanggal)
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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
H. HASIL TERAPI TERAKHIR :

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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL
 I. CATATAN PEMBIMBING PRAKTEK:
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PEMBIMBING

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NIP/NIK.

J. CATATAN TAMBAHAN:
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Blanko Laporan Status Klinik DIII FISIOTERAPI, FIK UNIKAL