Nomor RM : ……………….…..............................…….

PENGKAJIAN MEDIS RAWAT INAP Nama : ………………..……............................….

BAYI BARU LAHIR Tanggal Lahir : ...............................................................
( Dilengkapi dalam 24 jam )
RUMAH SAKIT Jenis Kelamin : L / P
PERTAMINA DUMAI
(dapat ditempelkan Barcode idetintas pasien)

Tanggal/ Jam mulai pengkajian : ................................................../..........................

A. ANAMNESIS
1. Riwayat penyakit sekarang
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2. Riwayat kehamilan dan persalinan :………………………………………………………………………………………………………...…...........
Riwayat penyakit selama kehamilan :........................................................................................................................................... ...................
B. PEMERIKSAAN FISIK
1. Keadaan Umum □ Sakit Ringan □ Sakit Sedang □ Sakit Berat
2. Kesadaran □ Sadar aktif □ Letargis □ Lain-lain ...............................................................................

PENGKAJIAN RAWAT INAP

3. Kepala : Bentuk/Ukuran □ Normal □ Abnormal ................................................................................................
4. Ubun - ubun □ Datar □ Cekung □ Menonjol
5. Wajah □ Normal □ Abnormal ................................................................................................
6. Mata □ Normal □ Abnormal ................................................................................................
7. THT □ Normal □ Abnormal ...............................................................................................
8. Mulut dan Rongga Mulut □ Normal □ Abnormal ...............................................................................................
9. Pernafasan □ Normal □ Abnormal ...............................................................................................
10. Bentuk Dada □ Normal □ Asimetri □ Retraksi
11. Gerakan Dada □ Normal □ Abnormal ...............................................................................................
12. Jantung □ Normal □ Abnormal ...............................................................................................
13. Abdomen □ Normal □ Abnormal ................................................................................................
15. Ekstremitas □ Normal □ Abnormal ...............................................................................................
16. Tulang Belakang □ Normal □ Abnormal ...............................................................................................
17. Genitalia : Laki-laki/ □ Phimosis □ Testis Kanan +/- □ Testis kiri +/- □ Hernia □ Hidrokel Testis
18. Perempuan □ Labia Minor Tertutup □ Labia Minor Menonjol
19. Miksi +/-
20 Anus +/- Mekonium + / -
21. Neurologis □ Refleks Pegang □ Refleks Hisap □ Refleks Moro □ Refleks Rooting
22. Tanda Lahir/Birth Mark ........................................................................................................................................... ......................
23 Kelainan Bawaan ............................................................................................................................................ .....................
.
PENILAIAN APGAR
MENIT
SIGN SKOR 2 SKOR 1 SKOR 0
I 5
Tonus otot □ Gerakan kuat □ Gerakan lemah dan sedikit □ Tidak ada gerakan
Denyut jantung □ Kuat , Nadi > 100 x/menit □ Lemah, Nadi < 100 x/menit □ Tidak ada/ tidak terdengar
□ Menangis kuat saat di beri □ meringis, merintih/ menagis saat
Kepekaan/ reflex □ Tidak ada respon diber stimulasi
stimulasi lemah diberi stimulasi
Warna kulit □ Merah muda/kemerahan □ Kemerahan , extremitas biru pucat □ Pucat dan sianosis
Pernafasan □ Baik dan teratur □ Lemah dan tidak teratur □ Tidak ada pernafasan
Total Skor : ................

FRM-Info-RM/027/2017 rev 02
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Catatan :

PEMERIKSAAN PENUNJANG ( Laboratorium, Radiologi, dll )

DIAGNOSA

C. KONSUL

RENCANA DAN TERAPI

Perkiraan lama rawat : ...................................................................................................................

DPJP ( Dokter Penanggung Jawab Pelayanan )

Tanggal/ jam selesai pemeriksaan : Nama : Tanda tangan :

…………………………………/……..…………….. ..................................................................... ……………………………………………

FRM-Info-RM/027/2017 rev 02
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FRM-Info-RM/027/2017 rev 02
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