STIKes CIREBON Nomor Urut : / /

DIII FISIOTERAPI

LAPORAN STATUS KLINIK

NAMA MAHASISWA : ________________________________________

NIM : ________________________________________

TEMPAT PRAKTIK : ________________________________________

PEMBIMBING : ________________________________________

Tanggal Pembuatan Laporan : __________________________________

Kondisi/ Kasus : FT A/ FT B/ FT C/ FT D/ FT E *)

*) Coret yang tidak perlu

I. KETERANGAN UMUM PENDERITA

Nama : ________________________________________

Umur : ________________________________________

Jenis Kelamin : ________________________________________

No. RM : ________________________________________

Agama : ________________________________________

Pekerjaan : ________________________________________

Alamat : ________________________________________

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II. DATA-DATA MEDIS RUMAH SAKIT

A. DIAGNOSA MEDIS:

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B. CATATAN KLINIS :

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C. TERAPI UMUM (GENERAL TREATMENT):

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D. RUJUKAN FISOTERAPI DARI DOKTER:

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III. SEGI FISIOTERAPI

TANGGAL:___________________________

A. ANAMNESIS (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 (KETERANGAN UMUM PENDERITA):

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6. RIWAYAT KELUARGA:

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7. ANAMNESIS SISTEM:

a) Kepala & Leher :

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b) Kardiovaskuler :

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c) Respirasi :
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d) Gastrointestinalis :

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e) Urogenitalis :

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f) Muskuloskeletal :

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g) Nervorum :

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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:

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1.3 PALPASI:

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1.4 PERKUSI:

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1.5 AUSKULTASI:

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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 & INTERPERSONAL:

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 1.8 KEMAMPUAN FUNGSIONAL & LINGKUNGAN
AKTIVITAS:
a) Kemampuan Fungsional Dasar:
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b) Aktivitas Fungsional:
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c) Lingkungan Aktivitas:
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2. PEMERIKSAAN SPESIFIK (FT A/ FT B/ FT C/ FT D/ FT E)*)

2.1 ____________________________________________________

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2.2 ____________________________________________________

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2.3 ____________________________________________________

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2.4 ____________________________________________________

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C. DIAGNOSIS FISIOTERAPI

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D. PROGRAM/ RENCANA FISIOTERAPI
1. TUJUAN:
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2. TINDAKAN FISIOTERAPI:
a. Teknologi Fisioterapi:
1) Teknologi Alternatif:
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2) Teknologi Yang Dilaksanakan:

(Jelaskan argumen/ alasan mengapa ini yang dilaksankan)
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b. Edukasi:
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3. RENCANA EVALUASI:
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E. PROGNOSIS:

Quo ad Vitam : ___________________

Quo ad Sanam : ___________________

Quo ad Fungsionam : ___________________

Quo ad Cosmeticam : ___________________

F. PELAKSANAAN FISIOTERAPI:

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G. EVALUASI:

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H. HASIL TERAPI TERAKHIR:

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I. CATATAN PEMBIMBING PRAKTIK:

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......./......................2019
PEMBIMBING

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NIP.
B. CATATAN TAMBAHAN:
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