STATUS KLINIS FISIOTERAPI NEUROMUSKULER (SSP)

A. IDENTITAS KLIEN
1. No. MR :
2. Nama :
3. Jenis kelamin :
4. Tempat/Tanggal Lahir :
5. Alamat :
6. Agama :
7. Pekerjaan :
8. Hobi :
9. Tanggal Masuk : Tgl Pemeriksaan :
10. Diagnosa Medis : Tgl serangan :
11. Medika mentosa :

B. ASESMEN/PEMERIKSAAN
1. Anamnesis
a. Keluhan Utama :
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b. Keluhan penyerta :
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c. Riwayat Penyakit Sekarang :
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d. Riwayat Penyakit Dahulu :
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PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

 e. Riwayat Sosial :
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f. Kemampuan Sebelumnya :
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g. Goal/Harapan Klien :
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2. Pemeriksaan Umum
a. Kesadaran :
b. Tekanan darah :
c. Denyut nadi :
d. Pernafasan :
e. Kesadaran :
f. Kognisi dan Persepsi:
3. Pemeriksaan Fisioterapi
a. Observasi

Keterangan:

: Nyeri

: Hipertonus

: Hipotonus

: Kelemahan

: Spastik

(Tandai bagian tubuh yang bermasalah)

PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

b. Kemampuan sensorik :
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c. Kondisi keseimbangan :
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d. Koordinasi
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e. Kemampuan fungsional
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f. Analisa Gerakan (General Postural Alignment, Kualitas Gerakan,
Kompensasi, Pola Gerakan, Gerakan Involunter)
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PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

 g. Deformitas/ kecacatan
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h. Pemeriksaan Khusus dan Pengukuran (Menggunakan assesment tools)
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4. Pemeriksaan Penunjang
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PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

C. DIAGNOSA FISIOTERAPI
1. Problematik Fisioterapi
a. Body Function and Structure Impairment :
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b. Activity Limitation :
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c. Participation Restriction:
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2. Diagnosa Fisioterapi berdasarkan ICF
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D. PERENCANAAN FISIOTERAPI
1. Tujuan Jangka Pendek
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2. Tujuan Jangka Panjang
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PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

E. INTERVENSI FISIOTERAPI
1. Intervensi Fisioterapi (Uraian Goal, Metode, Dosis, SOP)
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2. Edukasi/ Home Programe
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PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

F. EVALUASI (SOAP dan tuliskan tanggal)
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Jakarta, ................................ 2016

Menyetujui ,
Pembimbing Lahan Mahasiswa yang Menangani,

( ) ( )
NIP: NIM:

PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016