KEMENTERIAN KESEHATAN RI Nomor Urut : / / .

POLITEKNIK KESEHATAN SURAKARTA

JURUSAN FISIOTERAPI
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LAPORAN STATUS KLINIK

NAMA MAHASISWA : ____________________________________
N.I.M. : ____________________________________
TEMPAT PRAKTEK : ____________________________________
PEMBIMBING : ____________________________________
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Tanggal Pembuatan Laporan : _______________________
Kondisi / kasus : FT A / FT B / FT C / FT D / FT E *)

I. KETERANGAN UMUM PENDERITA

Nama : ________________________________________
Umur : ________________________________________
Jenis Kelamin : ________________________________________
Agama : ________________________________________
Pekerjaan : ________________________________________
Alamat : ________________________________________
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II. DATA-DATA MEDIS RUMAH SAKIT

A. DIAGNOSIS MEDIS :
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B. CATATAN KLINIS :

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*)
Coret yang tidak perlu

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 C. TERAPI UMUM ( GENERAL TREATMENT ) :

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D. RUJUKAN FISIOTERAPI DARI DOKTER :

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III. SEGI FISIOTERAPI

TANGGAL : ______________
A. A N A M N E S I S ( AUTO / HETERO *))
1. KELUHAN UTAMA :

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2. RIWAYAT PENYAKIT SEKARANG :
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 3. RIWAYAT PENYAKIT DAHULU :

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4. RIWAYAT PENYAKIT PENYERTA :

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5. RIWAYAT PRIBADI ( KETERANGAN UMUM PENDERITA ) :

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6. RIWAYAT KELUARGA :

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7. ANAMNESIS SISTEM :
a) Kepala & Leher :

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b) Kardiovaskuler :

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 c) Respirasi :

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d) Gastrointestinalis :

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e) Urogenitalis :

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f) Muskuloskeletal :

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g) Nervorum :

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B. PEMERIKSAAN
1. PEMERIKSAAN FISIK
1.1. TANDA - TANDA VITAL :
a) Tekanan darah : ______________________
s) Denyut Nadi : ______________________
d) Pernapasan : ______________________
f) Temperatur : ______________________
g) Tinggi Badan : ______________________
f) Berat Badan : ______________________

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 1.2. INSPEKSI :

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1.3. PALPASI :

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1.4. PERKUSI :

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1.5. AUSKULTASI :

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1.6. GERAKAN DASAR :
a) Gerak Aktif :

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 b) Gerak Pasif :

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c) Gerak Isometrik Melawan Tahanan :

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1.7. KOGNITIF, INTRA PERSONAL & INTER PERSONAL :

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1.8. KEMAMPUAN FUNGSIONAL & LINGKUNGAN AKTIVITAS :
a) Kemampuan Fungsional Dasar :

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b) Aktivitas Fungsional :

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 c) Lingkungan Aktivitas :

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2. PEMERIKSAAN SPESIFIK (FT A / FT B / FT C / FT D / FT E *)

2.1.
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2.2.
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2.3.
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2.4.
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 C. DIAGNOSIS FISIOTERAPI

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D. PROGRAM / RENCANA FISIOTERAPI

1. TUJUAN :

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2. TINDAKAN FISIOTERAPI :
a. Teknologi Fisioterapi :
1) Teknologi Alternatif :

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 2) Teknologi Yang Dilaksanakan :
(Jelaskan argumentasi / alasan mengapa ini yang dilaksanakan)

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 b. Edukasi:

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3. RENCANA EVALUASI:

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E. PROGNOSIS :
Quo ad Vitam : ___________________
Quo ad Sanam : ___________________
Quo ad fungsionam : ___________________
Quo ad Cosmeticam : ___________________

F. PELAKSANAAN FISIOTERAPI :

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G. EVALUASI:

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H. HASIL TERAPI TERAKHIR :

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I. CATATAN PEMBIMBING PRAKTEK :

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_______________, _____________________

PEMBIMBING

(_________________________________)
NIP.

J. CATATAN TAMBAHAN :

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