KOLEGIUM PENYAKIT DALAM (KPD)

CATATAN MEDIK PASIEN

No. Reg. RS :
Nama Lengkap :
Tanggal Lahir : Umur : Tahun Jenis Kelamin : L/P
Alamat : No. Telp :

Pekerjaan : Status: Belum menikah / Menikah / Janda / Duda

Pendidikan : Jenis Suku : Agama :

Dokter :
Tanggal Masuk : Jam :

ANAMNESIS

Autoanamnesa Alloanamnesa

RIWAYAT PENYAKIT SEKARANG

Keluhan Utama : __________________________________________________

Riwayat Perjalanan Penyakit :
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RIWAYAT PENYAKIT DAHULU
Tahun Penyakit Tempat Perawatan Pengobatan dan Operasi

RIWAYAT KELUARGA Laki-laki Perempuan

X Meninggal (sebutkan sebab meninggal dan umur saat meninggal

RIWAYAT PRIBADI
Riwayat Alergi Riwayat imunisasi
Tahun Bahan / obat Gejala Tahun Jenis imunisasi

Hobi : ___________________________________________________
Olah Raga : ___________________________________________________
Kebiasaan Makanan : ___________________________________________________
Merokok : ___________________________________________________
Minum Alkohol : ___________________________________________________
Hubungan Seks : ___________________________________________________
Penggunaan obat-obatan : _________________________________________________
ANAMNESIS UMUM (Review of System)
Berilah Tanda Bila Abnormal dan Berikan Deskripsi

A. Umum
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B. Kulit
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C. Kepala dan Leher
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D. Mata
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E. Telinga
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F. Hidung
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G. Mulut dan Tenggorokkan
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H. Pernafasan
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I. Payudara
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J. Muskuloskeletal
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K. Sistem Saraf
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L. Emosi, Status Psikologis
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DESKRIPSI UMUM

Kesan Sakit Ringan Sedang Berat

Gizi
Berat Badan : …….. Kg Tinggi Badan : ……… Cm IMT : ……… kg/m²

TANDA VITAL
Kesadaran
Nadi Frekuensi : x/menit Deskripsi:
Tekanan darah Berbaring: Duduk:
Lengan kanan: mmHg Lengan kanan: mmHg
Lengan kiri : mmHg Lengan kiri : mmHg
Temperatur Aksila: °C Rektal :
Pernafasan Frekuensi : x /menit Deskripsi:

Kulit ___________________________________________________
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Kepala dan Leher ___________________________________________________
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Telinga ___________________________________________________
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Hidung ___________________________________________________
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Rongga Mulut ___________________________________________________
dan Tenggorokkan ___________________________________________________
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Mata ____________________________________________________
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Toraks Kiri Kanan ____________________________________________________
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Jantung ____________________________________________________
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Paru-paru ____________________________________________________
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Abdomen ____________________________________________________
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Ekstremitas ____________________________________________________
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Alat Kelamin ____________________________________________________
Laki-laki ____________________________________________________
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Perempuan ____________________________________________________
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Rektum ____________________________________________________
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Neurologi ____________________________________________________
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Laboratorium
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 RESUME DATA DASAR
(Diisi dengan Temuan Positif)

Oleh dokter :
Nama Pasien : No. RM :
1. KELUHAN UTAMA :
2. ANAMNESIS : (Riwayat Penyakit Sekarang, Riwayat Penyakit
Dahulu, Riwayat Pengobatan, Riwayat Penyakit Keluarga, dll)
nita, 42 tah

3. PEMERIKSAAN FISIK :

4. PEMERIKSAAN TAMBAHAN :
A. Laboratorium

B. Radiologi

C. Lain-lain
MASALAH DAN PENGKAJIAN

1. Masalah

Pengkajian

2. Masalah

Pengkajian

3. Masalah

Pengkajian
4. Masalah

Pengkajian

5. Masalah

Pengkajian

6. Masalah

Pengkajian
 RENCANA AWAL
Nama Penderita : No. MR Th
.
Rencana yang akan dilakukan masing-masing masalah
(meliputi rencana untuk diagnosa, penatalaksanaan dan edukasi)
No. Masalah Rencana Diagnosa Rencana Terapi Rencana Monitoring Rencana Edukasi

RENCANA AWAL
Nama Penderita : No. MR Th
 Rencana yang akan dilakukan masing-masing masalah
(meliputi rencana untuk diagnosa, penatalaksanaan dan edukasi)
No. Masalah Rencana Diagnosa Rencana Terapi Rencana Monitoring Rencana Edukasi
KESIMPULAN :

PROGNOSIS :
Ad vitam
Ad functionam
Ad sanationam