PROGRAM STUDI D-3 FISIOTERAPI

FAKULTAS ILMU KESEHATAN

UNIVERSITAS RESPATI YOGYAKARTA

LAPORAN STATUS KLINIK

FISIOTERAPI MUSCULOSKELETAL DAN ORTOPEDI

Tempat Praktek : Nama Mahasiswa :

No. MR : No Induk Mahasiswa :
Tanggal Pengkajian :

I. PENGKAJIAN :
IDENTITAS PASIEN

Nama : ________________________________________
Umur : ________________________________________
Jenis Kelamin : ________________________________________
Agama : ________________________________________
Pendidikan : ________________________________________
Pekerjaan : ________________________________________
Alamat : ________________________________________
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II. DATA- DATA MEDIS RUMAH SAKIT

A. DIAGNOSIS MEDIS :
tgl, _________________________________
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B. CATATAN KLINIS :
(Hasil : Foto Rontgen, uji Laboratorium, CT-Scan, MRI, EMG, EKG, EEG, dll
yang terkait dengan permasalahan fisioterapi).
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C. TERAPI UMUM ( GENERAL TREATMENT ) :

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D. RUJUKAN FISIOTERAPI DARI DOKTER :

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III. SEGI FISIOTERAPI

A. PEMERIKSAAN SUBYEKTIF (A N A M N E S I S AUTO / HETERO *))
1. KELUHAN UTAMA:
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2. RIWAYAT PENYAKIT SEKARANG (Perjalanan Penyakit dan Riwayat Pengobatan)

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3. RIWAYAT PENYAKIT DAHULU:
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4. RIWAYAT PRIBADI:
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5. PENYAKIT PENYERTA:
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6. RIWAYAT KELUARGA:
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7. DATA SOSIAL:
(Lingkungan kerja, tempat tinggal, aktivitas rekreasi dan diwaktu senggang,
aktivitas sosial)
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 8. ANAMNESIS SISTEM:
Sistem Keterangan
(tdk dikeluhkan, dalam batas normal)
Kepala dan Leher
Kardiovaskuler
Respirasi
Gastrointestinalis
Urogenital
Muskuloskletal
Nervorum

B. P E M E R I K S A A N OBYEKTIF
1. PEMERIKSAAN FISIK TANDA - TANDA VITAL:
a) Tekanan darah : ______________________
b) Denyut Nadi : ______________________
c) Pernapasan : ______________________
d) Temperatur : ______________________
e) Tinggi Badan : ______________________
f) Berat Badan : ______________________
2. INSPEKSI (STATIS & DINAMIS) (Posture, bengkak, gait, tropic change, dll):
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3. PALPASI (nyeri, spasme, suhu lokal, tonus, bengkak, dll):
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4. PERKUSI (refleks fisiologis):
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5. GERAKAN DASAR:
a Gerak Aktif :
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b Gerak Pasif:
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c Gerak Isometrik Melawan Tahanan:
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6. KOGNITIF, INTRA PERSONAL & INTER PERSONAL:

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7. KEMAMPUAN FUNGSIONAL & LINGKUNGAN AKTIVITAS (Pemeriksaaan

Toleransi Aktivitas):
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8. PEMERIKSAAN SPESIFIK (Nyeri, MMT, LGS, Antropometri, dan Test Khusus

sesuai Kasus)
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C. DIAGNOSIS FISIOTERAPI
a. Impairment
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b. Functional Limitation
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c. Disability
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D. PROGRAM/RENCANA FISIOTERAPI
1. Tujuan
a. Jangka Pendek
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b. Jangka Panjang
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2. TEKNOLOGI INTERVENSI
a. Teknologi Fisioterapi:
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b. E d u k a s i:
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3. RENCANA EVALUASI
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E. PENATALAKSANAAN FISIOTERAPI :
1. Hari: Tgl :
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F. E V A L U A S I:
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G. HASIL TERAPI TERAKHIR :

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H. CATATAN PEMBIMBING PRAKTEK:

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PEMBIMBING

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NIP/NIK.

I. CATATAN TAMBAHAN:
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