LAPORAN STATUS KLINIK D III FISIOTERAPI

FISIOTERAPI MUSKULOSKELETAL
Program Studi Fisioterapi

Nomor Urut : / /

NAMA MAHASISWA : ____________________________________

N.I.M. : ____________________________________
TEMPAT PRAKTIK : ____________________________________
PEMBIMBING : ____________________________________
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Tanggal Pembuatan Laporan : _______________________

I. KETERANGAN UMUM PENDERITA

Nama : ________________________________________
Umur : ________________________________________
Jenis Kelamin : ________________________________________
Agama : ________________________________________
Pekerjaan : ________________________________________
Alamat : ________________________________________
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No RM :________________________________________

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. SEGIFISIOTERAPI
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A. A N A M N E S I S (AUTO / HETERO *))
1. KELUHAN UTAMA:
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2. RIWAYAT PENYAKIT SEKARANG:

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 3. RIWAYAT PENYAKIT DAHULU:
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4. RIWAYAT PENYAKIT PENYERTA:

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5. RIWAYAT PRIBADI DAN KELUARGA:

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6. ANAMNESIS SISTEM:
Sistem Keterangan
(tdk dikeluhkan, dalam batas normal)
Kepala dan Leher
Kardiovaskuler
Respirasi
Gastrointestinalis
Urogenital
Muskuloskletal
Nervorum

B. PEMERIKSAAN
1. PEMERIKSAAN FISIK
1.1. TANDA - TANDA VITAL:
a) Tekanan darah : ______________________
b) Denyut Nadi : ______________________
c) Pernapasan : ______________________
d) Temperatur : ______________________
e) Tinggi Badan : ______________________
f) Berat Badan : ______________________

1.2. INSPEKSI (STATIS & DINAMIS) (Posture, bengkak, gait, tropic

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1.3. PALPASI (nyeri, spasme, suhu lokal, tonus, bengkak, dll):

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1.4. PERKUSI (refleks fisiologis):

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1.6. 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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1.7. KOGNITIF, INTRA PERSONAL & INTER PERSONAL:

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1.8. KEMAMPUAN FUNGSIONAL & LINGKUNGAN AKTIVITAS:

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1.9. PEMERIKSAAN
a. Nyeri
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b. MMT
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c. LGS
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d. Antropometri
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e. Test Khusus sesuai kelainan/penyakit/gangguan
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f. Dll.
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2.0 DIAGNOSIS FISIOTERAPI

a. Impairment
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b. Functional Limitations
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c. Disability
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C. PROGRAM/RENCANA FISIOTERAPI
1. Tujuan

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a. Jangka Pendek
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b. Jangka Panjang
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2. TINDAKAN FISIOTERAPI:
a. Teknologi Fisioterapi:
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b. E d u k a s i:
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3. R E N C A N A E V A L U A S I:
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F. PELAKSANAAN FISIOTERAPI:
1. Hari: Tgl:
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G. E V A L U A S I:
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H. HASIL EVALUASI TERAKHIR:
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J. CATATAN PEMBIMBING PRAKTIK:

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_______________, ______________20….
PEMBIMBING

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NIP/NIK.

K. CATATAN TAMBAHAN:
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L. Underlying Process

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