RSUP SANGLAH DENPASAR RM.10.8.1/REV.

1/ER/2019
Nama :
ASESMEN AWAL GAWAT DARURAT
MEDIS Tgl.Lahir: L/P
BEDAH NON TRAUMA No RM :
Tanggal:……………….. Jam:………..

Rujukan Ya  RS .......................................... Puskesmas ...........................................

dari  Dr. .........................................  Lainnya .................................................
Dx Rujukan ......................................................
Tidak  Datang Sendiri  Diantar..........................................................

ANAMNESA
1. Keluhan Utama:

2. Riwayat Penyakit Sekarang ( Jabarkan lokasi, onset, kronologis, kualitas/kuantitas keluhan tsb dan faktor-faktor/gejala yang
menyertainya):

3. Riwayat Pengobatan:

Riwayat penyakit
Hipertensi Diabetes Jantung Stroke Dialysis Asma Kejang Liver
Cancer TBC Glaukoma STD Perdarahan Lainnya…………………………….

Riwayat operasi : Tidak Ya, jenis &kapan ……………………

Riwayat Tranfusi : Tidak Ya Reaksi Transfusi : Tidak Ya, reaksi yang timbul…………

Riwayat penyakit dalam keluarga :

PEMERIKSAAN FISIK

Kepala  Normal  Abnormal .........................................................................................................................

Mata  Normal  Abnormal .........................................................................................................................
THT  Normal  Abnormal .........................................................................................................................
Leher  Normal  Abnormal .........................................................................................................................
Dada  Normal  Abnormal .........................................................................................................................
 Jantung  Normal  Abnormal .........................................................................................................................
 Paru  Normal  Abnormal .........................................................................................................................
Perut  Normal  Abnormal .........................................................................................................................
 Hepar  Normal  Abnormal .........................................................................................................................
 Lien  Normal  Abnormal .........................................................................................................................
Punggung  Normal  Abnormal .........................................................................................................................
Genital  Normal  Abnormal .........................................................................................................................
Ekstremitas  Normal  Abnormal .........................................................................................................................
Rectal Toucher  Normal  Abnormal .........................................................................................................................

1
RSUP SANGLAH DENPASAR RM.10.8.1/REV.1/ER/2019
STATUS LOKALIS SKEMA

HASIL PEMERIKSAAN PENUNJANG

DIAGNOSIS (ICD X)

RENCANA KERJA DOKTER ( CARE OF PLAN)

NO DAFTAR MASALAH RENCANA INTERVENSI TARGET
(kondisi yang diharapkan dan waktu)

2
RSUP SANGLAH DENPASAR RM.10.8.1/REV.1/ER/2019
Nama :
ASESMEN AWAL GAWAT DARURAT
MEDIS Tgl.Lahir: L/P
BEDAH NON TRAUMA No RM :
INSTRUKSI

DISPOSISI:
 Boleh pulang, Jam Keluar: ................ Wita Tanggal : .................................
Kontrol Poliklinik Ya, ................................. Tanggal : .................................  Tidak

 Dirawat di ruang:  Intensif  Ruang lain : .............................. Kelas ..................

 Di rujuk ke ............... Transportasi yang di sarankan : ......................................... Pendamping: Tidak Ya:
sebutkan:......................................

KONDISI SAAT DIPULANGKAN INSTRUKSI PULANG

Tanda Tangan dan Nama Dokter Pengkaji Tanda Tangan dan Nama DPJP