STATUS KLINIS FISIOTERAPI MUSKULOSKELETAL

A. IDENTITAS KLIEN
1. NRM :
2. Nama :
3. Jenis kelamin :
4. Tempat/Tanggal Lahir :
5. Alamat :
6. Agama :
7. Pekerjaan :
8. Hobi :
9. Tanggal masuk :
10. Diagnosa medis :
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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PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

 d. Riwayat Penyakit Dahulu :
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2. Pemeriksaan Umum
a. Kesadaran :
b. Tekanan darah :
c. Denyut nadi :
d. Pernafasan :
e. Kooperatif :

3. Pemeriksaan Fisioterapi
a. Inspeksi
1) Statis
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2) Dinamis
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b. Tes Cepat
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PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

c. Pemeriksaan Fungsi Gerak Dasar (PFGD)
1) PFGD Aktif
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2) PFGD Pasif
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3) PFGD Isometrik
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d. Tes Khusus
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PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

 e. Pemeriksaan Penunjang
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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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PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

 2. Tujuan Jangka Panjang
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E. INTERVENSI FISIOTERAPI
1. Intervensi Fisioterapi (Uraian Goal, Metode, Dosis, SOP)
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PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016

 2. Edukasi/ Home Programe
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F. EVALUASI (SOAP)
Tanggal:
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Jakarta, ................................ 2016

Menyetujui ,
Pembimbing Lahan Mahasiswa yang Menangani,

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NIP: NIM:

PRODI D-IV FISIOTERAPI POLTEKKES KEMENKES JAKARTA III, 2016