PEMERINTAH KABUPATEN SRAGEN No. RM : ................................................

RSUD dr. SOEHADI PRIJONEGORO SRAGEN Nama Pasien : ................................................

Jln. Raya Sukowati No. 534 Telp. (0271) 891068 Fax. 890158 Sragen 57215
SR
AGEN

Website http://www.rsspsragen.com
Tanggal Lahir : ................................................
E-mail : rsudsragen1958@gmail.com Jenis Kelamin : Laki-laki Perempuan
Alamat : ................................................
ASESMEN MEDIS GAWAT DARURAT ................................................
Pasien Masuk IGD Tanggal : Jam : WIB
TRIASE
ATS I ATS II ATS III ATS IV ATS V

IDENTITAS PENGANTAR PASIEN

Nama : .............................................................................................................................
Alamat : .............................................................................................................................
Hubungan dengan pasien : .............................................................................................................................
ANAMNESE
KELUHAN UTAMA : .............................................................................................................................

PERJALANAN PENYAKIT SEKARANG :

(Lokasi, Onset dan Kronologis, Kualitas, Faktor Memperberat, Faktor Memperingan, Gejala Penyerta)
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RIWAYAT PENYAKIT LAIN

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RIWAYAT PENYAKIT KELUARGA

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PEMERIKSAAN FISIK
1. Keadaan Umum : Baik Sedang Lemah GCS : E ........... V ........... M ............
2. Vital Sign : T : ........mm/Hg, N : ..........x/menit S : .......... °C RR : ..........x/menit
3. Kesadaran : compos mentis somnolen dellrium sopor koma
4. Cranium : ......................................................................................................................................
Hidung : ......................................................................................................................................
Mulut : ......................................................................................................................................
Mata : ......................................................................................................................................
Gigi : ......................................................................................................................................
Telinga : ......................................................................................................................................
5. Leher : ......................................................................................................................................
6. Thorax : ......................................................................................................................................
Jantung : ......................................................................................................................................
Paru : ......................................................................................................................................
7. Abdomen : ......................................................................................................................................
Hepar : ......................................................................................................................................
Lien : ......................................................................................................................................
Ginjal : ......................................................................................................................................
8. Genetalia : ......................................................................................................................................
9. Ekstremitas atas : ......................................................................................................................................
Ekstremitas bawah : ......................................................................................................................................

RM : 1b/Rev.2/2019 Asesmen Medis Gawat Darurat I Hal.1

 PEMERIKSAAN TAMBAHAN
Status Luka :
( Regio, jenis luka, ukuran )
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Status Tulang / fraktur
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TINDAKAN YANG SUDAH DIBERIKAN SEBELUM MASUK RS
( Termasuk pemeriksaan penunjang dan obat yang di konsumsi )
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PEMERIKSAAN PENUNJANG
Laboratorium : ...................................................................................................................................
Radiologi : ...................................................................................................................................
EKG : ...................................................................................................................................
Pemeriksaan Khusus : ...................................................................................................................................
DIAGNOSIS KERJA
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DIAGNOSIS BANDING (Bila Ada)
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TERAPI
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RENCANA TINDAK LANJUT

Rawat Jalan Dirujuk RS : ...................................
Rawat Inap Atas dasar :
DPJP : ......................... Kamar penuh Perlu fasilitas dan SDM
Ruang : ......................... Diantar oleh
Meninggal di IGD Ambulan RS Ambulan Lain
Tanggal : ........................ Jam ...................
KONDISI KEPULANGAN
Keadaan Umum : Baik Sedang Lemah GCS : ................................
Tanda Vital : T : ............mm/Hg, N : ..................X/Menit, S : .......... °C
Pemeriksaan Fisik : ...................................................................................................................................
Tanggal dan Jam : ...................................................................................................................................

Sragen, .............................. Jam ........... WIB

Dokter Jaga IGD

( ................................ )
Tanda tangan dan nama terang
RM : 1b/Rev.2/2019 Asesmen Medis Gawat Darurat I Hal.2