RM

ASESMEN MEDIS RAWAT JALAN

IDENTITAS PASIEN
No. Rekam
No. RekamMedis
Medik : ............................................................... Tanggal Asesmen
: …………………………………………………………… : ..................................Jam............... WIB
NIK
Nama Pasien : ……………………………………………………………
: ............................................................... Klinik : ...............................................................
Nama Pasien : ……………………………………………………………
TanggalLahir
Tanggal Lahir : ……………………………………………………………
: ...............................................................

ANAMNESIS
Keluhan Utama
.................................................................................................................................................................................................
.................................................................................................................................................................................................
Riwayat Penyakit (Riwayat sekarang, dahulu dan keluarga)
.................................................................................................................................................................................................
.................................................................................................................................................................................................
Riwayat Alergi Tidak
Ya, Bahan Alergen : ..........................................................................................................................
Obat obat yang sedang dikonsumsi :
.................................................................................................................................................................................................
.................................................................................................................................................................................................

PEMERIKSAAN FISIK
Tekanan darah : ............................mmHg Berat Badan.................................. kg
Nadi : ............................x/menit Tinggi Badan................................. cm
Suhu : ............................C Kondisi Nutrisi : obesitas / overweight / normoweight / underweight
RR : ............................x/menit SpO2 ............................................ %
Kesadaran compos mentis apatis delirium coma lainnya : ................................................
GCS :E V M
Status Lokalis

HASIL PEMERIKSAAN PENUNJANG

Laboratorium :

Radiologi :

ECG :

Lain lain :
 Diagnosa Kerja dan Banding

Permasalahan / Daftar Masalah

Medis :

Keperawatan:

Penatalaksanaan Terapi/Pengobatan/Rencana Tindakan

Anjuran

Kontrol kembali :

Edukasi awal tentang diagnosa, rencana tindakan, tujuan terapi kepada : Pasien / Keluarga

Pasien
Keluarga pasien, nama :.................................................................................................
hubungan dengan pasien : ...............................................................................................
Tidak dapat memberi edukasi kepada pasien atau keluarga,
karena : ............................................................................................................................ ................................................
(Nama terang & Tanda tangan)

DPJP

................................................
(Nama terang & Tanda tangan)