B.

ASESMEN MEDIS
Tanggal Masuk : Jam Masuk:
1. SUBJEKTIF Auto Allo, diberikan oleh ......................................... Alergi : tidak
Hubungan dengan pasien ................................... Ya, sebutkan 1.
Keluhan utama .......................................................................................... 2.
.................................................................................................................... 3.
.................................................................................................................... Riwayat penyakit dahulu
Riwayat penyakit sekarang : ...................................................................... .................................................................................
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.................................................................................................................... Riwayat penggunaan obat
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2. OBJEKTIF : GCS : E............V............M...............
Keadaan Umum : Baik Sedang Buruk
Tanda Vital : Tekanan Darah ...................mmHg Nadi ................... x/menit Respirasi ............ x/menit
Suhu .....................*C Berat Badan .................Kg Tinggi Badan ................Cm
3. Pemeriksaan Fisik
Kepala : .......................................................
Mata : .......................................................
Mulut : ........................................................
Leher : .......................................................
Thorak : .......................................................
Cor : .......................................................
Pulmo : ........................................................
Abdomen : ........................................................
Ekstremitas : ........................................................
Anus-genetalia : .......................................................
4. PEMERIKSAAN PENUNJANG
Lab : ................................................................................................
.................................................................................................
Rontgen : .........................................................................................
CT Scan : .........................................................................................
Lain-lain : ...............................................................................
Diagnosis Kerja : ....................................................................................
...................................................................................................................
................................................................................................................... Keterangan : ..........................................................
................................................................................................................. ..........................................................
5. RENCANA PENATALAKSANAAN ( Terapi / Rencana Tindakan )
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6. TINDAK LANJUT ( Perencanaan Pemulangan Pasien )
Kontrol Untuk Berobat Jalan : Tidak Ya, Hari/Tanggal
Dirawat Inap. Ruangan : .......................................................................................................................
Menolak Dirawat, Alasan : .......................................................................................................................
Dirujuk Ke Rs : ........................................................ Atas Dasar .............................................
Dirujuk Ke Spesalis : .......................................................................................................................
7. Komunikasi Informasi Edukasi Diberikan Kepada : Pasien keluarga pasien, nama .....................................................

Kediri, .........../............/........ Jam: .........

Dokter pemeriksa

Catatan :
- Beri Tanda ( ) Untuk Kotak Yang Di Isinya
- Asesmen Awal Rajal Dilakukan Tiap 1 Bulan Untuk Pasien Akut (........................................................)
Dan 3 Bulan Untuk Pasien Kronis