LEMBAR KAJIAN AWAL MEDIS

Nama : NOMER REKAM MEDIK

Tanggal Lahir :
Jenis Kelamin : L/P
Alamat : Ruang :
Data diisi selambat-lambatnya 24 jam setelah pasien masuk dan ditanda tangani DPJP
Tanggal : ................................................................. Jam : ......................................

Keluhan
Utama : ...................................................................................................................................................
.................................................................................................................................................................
..............

Riwayat Penyakit
Sekarang : ...............................................................................................................................................
.................................................................................................................................................................
..................
Riwayat Penyakit
Dahulu : ...................................................................................................................................................
.................................................................................................................................................................
.............
Riwayat Penyakit
Keluarga : ................................................................................................................................................
.................................................................................................................................................................
.................
Pemeriksaan Fisik
Keadaan Umum : ....................................................................................................................................
.....................................................................................................................................
Tanda Vital
Tek. Darah : / mmHg Nadi : x/menit SPO 2 : %
O
Suhu : C Pernafasan : x/menit

Skala
Nyeri : ......................................................................................................................................................
.................................................................................................................................................................
...........
Kepala :
.................................................................................................................................................................
.................................................................................................................................................................
Leher : .....................................................................................................................................................
.................................................................................................................................................................
............
Thorax : ...................................................................................................................................................
.................................................................................................................................................................
..............
Abdomen : ..............................................................................................................................................
.................................................................................................................................................................
...................
Ekstremitas : ..............................................................................................................................................
....................................................................................................................................................................
....................
Pemeriksaan Penunjang :

Diagnosis :
Tindakan :
Terapi :

Rencana Diit :
 DOKTER

( )