PEMERINTAH KABUPATEN KENDAL

DINAS KESEHATAN
PUSKESMAS NGAMPEL
Jl. Sunan Ampel Km.2 Ngampel Kendal (0294)383084Kode Pos 51357
e-mail : ngampelinduk2014@gmail.com

PENGKAJIAN ULANG No Rekam Medik :

PASIEN RAWAT JALAN Nama Pasien : L/P
( Untuk pasien dengan pemeriksaan lebih dari 30 hari setelah kunjungan terakhir ) Tanggal Lahir :
Alamat :
Status : UMUM/BPJS (No : ...........................)
Unit Pelayanan : Tanggal : Jam :
1. SUBYEKTIF
Keluhan Utama :
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Keluhan tambahan :
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Riwayat penyakit sekarang :
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Riwayat penyakit dahulu :
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Riwayat Penyakit Keluarga :
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Riwayat Alergi :
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Tindakan / terapi yang pernah dijalani :
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Obat yang sering dikonsumsi :
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Obat yang sedang dikonsumsi :
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2. OBYEKTIF
Keluhan Umum : baik sedang lemah PEMERIKSAAN FISIK
GSC : E................ / V ................. / M ............ Kepala / leher : ...........................................................
Tanda-tanda vital: TD : ...................... mmHg Thorax : ...........................................................
Nadi : .................... x/menit Abdomen : ...........................................................
Suhu : .................... ° C Extremitas : ...........................................................
RR : .................... x/menit Lainnya : ...........................................................

STATUS GIZI PEMERIKSAAN PENUNJANG

Berat Badan : ......................... kg
Tinggi Badan : ......................... cm
IMT : .........................
3. ASSESMENT
Diagnosa Medis
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4. PLANNING
Rencana Pelayanan Medis
A. Rencana Tindakan / Pengobatan :
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Diagnosa Keperawatan
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Rencana Asuhan Keperawatan
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B. Rencana Edukatif
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C. Rencana Diagnostik
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D. Rencana Monitoring
Kontrol kembali tanggal :
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Lainnya :
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E. Rencana Rujukan
Rujuk ke RS : ........................ Poli : ....................
F. Rencana Pelayanan Lainnya
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Dokter Penanggung Jawab Pelayanan,
Nama Terang dan Tanda Tangan
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Perawat,
Nama Terang dan Tanda Tangan