CATATAN PERAWATAN PASIEN

Kamar :
UPTD PUSKESMAS DTP JAMANIS
Jln. Raya Jamanis No. 33 Tasikmalaya __________________

Nama : _______________________ Status : Umum / BPJS / Jamkesda / UPCPK

Jenis Kelamin : L / P Pekerjaan : ______________________
Umur : ___ Bln / Thn Agama : ______________________
Alamat : Kp. ____________________ Penanggung Jawab : ______________________
Desa : ________________________ Tanggal Masuk : / / jam :……….
Kecamatan : ________________________ Tanggal Keluar : / / jam :……….
No. Telepon : ________________________ Keadaan Pasien : Sembuh / dirujuk / meninggal / PP

Keluhan Utama : ______________________________________

Anamnesa : _________________________________________________________________
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Pemeriksaan Fisik : TD : ____/____ mmHg Nadi : ___ x/mnt BB : ____ kg
Nafas : ___ x/mnt Suhu : ____ 0C TB : ____ cm
Kepala : __________________________________________________________
Thorax : __________________________________________________________
Abdomen : ________________________________________________________
Extremitas : _______________________________________________________

Diagnosa : _________________________________________________________________
Tindakan : _________________________________________________________________
Laboratorium :_________________________________________________________________
Therapi : _________________________________________________________________
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Yang Memeriksa

dr. _______________________