UPTD PUSKESMAS PAGERAGEUNG No RM

: ......................................
Jl. Tanjaknangsi No. 23 Desa Pagerageung Tlp/Fax: (0265) 455519
Website: www.pkmpagerageung.net e-mail : Nama : ................................L/P
pkm.pagerageung@gmail.com
Pagerageung - Kode Pos 46158 Tgl Lahir/Umur : .....................................
CATATAN PERKEMBANGAN PASIEN
Jenis pelayanan: Tanggal: Jam : Nama dan
Paraf Petugas
S Keluhan Utama :
O Vital Sign : TD: mmHg R: x/mnt TB: cm
○
N: x/mnt S: c BB: kg
Pemeriksaan fisik*(tidak diisi data pasien unit pemeriksaan gigi dan mulut)
Kepala : .............................................................................................................................
Thorak : .............................................................................................................................
Abdomen : .............................................................................................................................
Extremitas : ............................................................................................................................
A Diagnosis: …………………………………………………... Diagnosa keperawatan/kebidanan:
DD: ……………………………………........................... ...................................................................
ICD X : ……………………………… ……....................... ...................................................................
P Tindakan: …………………………………………………..... Catatan keperawatan/kebidanan:
…………………………………………………….................. ...................................................................
Therapi : ..................................................................
…………………………………...................................... ...................................................................
…………………………………...................................... ...................................................................
…………………………………...................................... ..................................................................
…………………………………...................................... ...................................................................
Pemeriksaan ...................................................................
Penunjang........................................................ ...................................................................
Rujuk : YA / TIDAK Internal : .............................................................................................
Eksternal : RS .......................................Poli ........................................

Edukasi : …………………………………………….……………………………………………………………………………

Jenis pelayanan: Tanggal: Jam : Nama dan

Paraf Petugas
S Keluhan Utama :
O Vital Sign : TD: mmHg R: x/mnt TB: cm
○
N: x/mnt S: c BB: kg
Pemeriksaan fisik*(tidak diisi data pasien unit pemeriksaan gigi dan mulut)
Kepala : .............................................................................................................................
Thorak : .............................................................................................................................
Abdomen : .............................................................................................................................
Extremitas : ............................................................................................................................
A Diagnosis: …………………………………………………... Diagnosa keperawatan/kebidanan:
DD: ……………………………………........................... ...................................................................
ICD X : ……………………………………....................... ...................................................................
P Tindakan: …………………………………………………..... Catatan keperawatan/kebidanan:
…………………………………………………….................. ...................................................................
Therapi : ..................................................................
…………………………………...................................... ...................................................................
…………………………………...................................... ...................................................................
…………………………………...................................... ..................................................................
…………………………………...................................... ...................................................................
Pemeriksaan ...................................................................
Penunjang........................................................
Rujuk : YA / TIDAK Internal : .............................................................................................
Eksternal : RS .......................................Poli ........................................

EdukasI : …………………………………………………………………………………………………………………………….
Hal 1/2 023/rev01/URM/2023
 CATATAN PERKEMBANGAN PASIEN
Jenis pelayanan: Tanggal: Jam : Nama dan
Paraf Petugas
S Keluhan Utama :
O Vital Sign : TD: mmHg R: x/mnt TB: cm
○
N: x/mnt S: c BB: kg
Pemeriksaan fisik*(tidak diisi data pasien unit pemeriksaan gigi dan mulut)
Kepala : .............................................................................................................................
Thorak : .............................................................................................................................
Abdomen : .............................................................................................................................
Extremitas : ............................................................................................................................
A Diagnosa keperawatan/kebidanan:
Diagnosis: …………………………………………………... ...................................................................
DD: …………………………………….......................... ...................................................................
ICD X : …………………………………….....................
P Tindakan: …………………………………………………..... Catatan keperawatan/kebidanan:
…………………………………………………….................. ...................................................................
Therapi : ..................................................................
…………………………………...................................... ...................................................................
…………………………………...................................... ...................................................................
…………………………………...................................... ..................................................................
…………………………………...................................... ...................................................................
…………………………………..................................... ...................................................................
Pemeriksaan ...................................................................
Penunjang........................................................
Rujuk : YA / TIDAK Internal : .............................................................................................
Eksternal : RS .......................................Poli ........................................

Edukasi :…………………………………………………………………………………………………………………………

Jenis pelayanan: Tanggal: Jam : Nama dan

Paraf Petugas
S Keluhan Utama :
O Vital Sign : TD: mmHg R: x/mnt TB: cm
○
N: x/mnt S: c BB: kg
Pemeriksaan fisik*(tidak diisi data pasien unit pemeriksaan gigi dan mulut)
Kepala : .............................................................................................................................
Thorak : .............................................................................................................................
Abdomen : .............................................................................................................................
Extremitas : ............................................................................................................................
A Diagnosa keperawatan/kebidanan:
Diagnosis: …………………………………………………... ...................................................................
DD: ……………………………………........................... ...................................................................
ICD X : …………………………………….......................
P Tindakan: …………………………………………………..... Catatan keperawatan/kebidanan:
…………………………………………………….................. ...................................................................
Therapi : ..................................................................
…………………………………...................................... ...................................................................
…………………………………...................................... ...................................................................
…………………………………...................................... ..................................................................
…………………………………...................................... ...................................................................
Pemeriksaan ...................................................................
Penunjang............................................ ...................................................................
Rujuk : YA / TIDAK Internal : .............................................................................................
Eksternal : RS .......................................Poli ........................................

Edukasi : …………………………………………………………………………………………………………………………

Hal 2/2 023/rev01/URM/2023

Hal 2/2 003/rev01/URM/2021