KLINIK PRATAMA MUTHMAINNAH

Jl. Kol Amir Hamzah No.33 RT.24, Kel. Selamat, Kec Danau Sipin
HP : 081279775976 Email: klinik.muthmainnah28@gmail.com

PENGKAJIAN AWAL RAWAT JALAN Nama :

No. RM :
Tgl. Lahir :
No BPJS / NIK :
PENGKAJIAN KEPERAWATAN

1. KELUHAN UTAMA :

2. PEMERIKSAAN FISIK :
BB : ...................... kg TB : ........................cm RR : ...................x/i
TD : ......................mmHg Nadi : ........................x/i N : ...................C
3. RIWAYAT KESEHATAN
a. Riwayat penyakit lalu : Tidak Ya , penyakit ................................................
b. Riwayat penyakit keluarga : Tidak Ya Hipertensi

ALERGI TERHADAP :
1. JENIS KASUS BEDAH
NON BEDAH Interne Anak Obsgin Lainnya .....................
Tindakan Resusitasi : YA TIDAK
2. ANAMNESA & PEMERIKSAAN FISIK
a. Anamnesa : ...................................................................................................................
...................................................................................................................
....................................................................................................................
b. Pemeriksaan Fisik : KU : ............................................................................................................
Tensi : .......... Nadi : ......... Suhu : ......... Nafas : ...........
Kepala : ....................................
.....................................
Thorax : ....................................
....................................
Abdumen : ....................................
....................................
Extremitas : ....................................
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Catatan *) Coret yang tidak perlu

Beri tanda “x” pada yang sesuai
NAMA : ................................... No. RM : ............................
Jenis Kelamin : Lk Pr Umur : .......... Th/Bln/Hari

c. Laboratorium : .....................................................................................................................
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d. Pem. Radiologi : .....................................................................................................................
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e. Pem. Lainnya : .....................................................................................................................
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3. DIAGNOSIS KERJA : .....................................................................................................................
.....................................................................................................................
4. INFORM CONSENT :
Telah menerima penjelasan mengenai tindakan medis beserta akibat / resiko dan TIDAK
KEBERATAN/ SETUJU dilakukan tindakan medis yang telah dijelaskan oleh petugas UGD.
Telah menerima penjelasan mengenai tindakan medis beserta akibat / resiko dan MENOLAK
untuk dilakukan tindakan medis yang telah dijelaskan oleh petugas UGD.

Jambi, ..............................
Yang diberi penjelasan

Nama : .................................................
Org Tua/Wali/Penanggungjawab/pasien
5. TERAPI / TINDAKAN
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
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6. TINDAK LANJUT
Dipulangkan untuk kontrol berobat jalan pada klinik .................................... Tgl ..................
Dirujuk ke ...................................... atas dasar Tempat Penuh Permintaan Pasien
Menolak dirawat :
Meninggal Dunia : Tanggal : ................................... Pukul .....................................WIB

7. CATATAN LAIN
........................................................................................................................................................
........................................................................................................................................................

Nama Bidan /Perawat UGD Jambi, .....................................

1) .................................................. Dokter
2) ..................................................
3) ..................................................
4) ..................................................
Nama : ..................................

Catatan *) Coret yang tidak perlu

Beri tanda “x” pada yang sesuai