Nama Koas / STB :

Tanggal :

Topik

STATUS PASIEN MPPD INTERNA (RAWAT INAP/POLI/PUSKESMAS)

Nama Lengkap :
Tanggal lahir :
Umur : tahun Jenis kelamin : L / P
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Alamat : No. Rekam Medis

Pekerjaan : Status : Belum menikah / Menikah / Janda / Duda

Pendidikan : Etnis / Suku : Agama :

ANAMNESIS
Autoanamnesis Alloanamnesis
RIWAYAT PENYAKIT SEKARANG
Keluhan Utama : ______________________________________________________
Riwayat perjalanan penyakit :
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RIWAYAT PENYAKIT DAHULU
Tanggal Penyakit Tempat Perawatan Pengobatan / Operasi

RIWAYAT PRIBADI
Riwayat Alergi Riwayat Imunisasi

Tahun Bahan/Obat Gejala Tahun Jenis Imunisasi

Hobi :___________________________________________________________
Olah Raga : ___________________________________________________________
Kebiasaan Makan : ___________________________________________________________
Merokok : ___________________________________________________________
Minum Alkohol : ___________________________________________________________
Hubungan Seks : ___________________________________________________________
Penggunaan Obat-obatan : ___________________________________________________________
Riwayat Kandungan : ___________________________________________________________

DESKRIPSI UMUM
Kesadaran : Komposmentis/apatis/delirium/somnolen/sopor/koma
GCS : E:….. M:…… V:…….
Kesan Sakit : ringan / sedang / berat
Gizi :
Berat Badan : …………… Kg; Tinggi badan : ……………… cm; IMT : ……Kg/m2
TANDA VITAL
Kesadaran :
Nadi Frekuensi :……………… / menit, Deskripsi :
Tekanan Darah Berbaring mmHg Duduk : mmHg
o o
Temperatur Aksilla : C Rektal : C
Pernafasan Frekuensi :………………./ menit Deskripsi :

PEMERIKSAAN FISIK :
Kepala dan Leher
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Thorax Kiri Kanan (Inspeksi)
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Jantung
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Paru-paru
 Palpasi
 Perkusi
 Auskultasi
Keterangan ditulis di samping gambar

Abdomen
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Ekstremitas
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Rektum
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Status Lokalis
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Pemeriksaan Penunjang
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 RESUME DATA DASAR
(Diisi Dengan Temuan Positif)

1. KELUHAN UTAMA :
2. ANAMNESIS : (Riwayat Penyakit Sekarang, Riwayat Penyakit Dahulu, Riwayat Pengobatan,
Riwayat Keluarga, dll)

3. PEMERIKSAAN FISIK

4. PEMERIKSAAN PENUNJANG

5. LAIN-LAIN
MASALAH DAN PENGKAJIAN
1. Masalah :
Pengkajian :

2. Masalah :
Pengkajian :

3. Masalah :
Pengkajian :

4. Masalah :
Pengkajian :

5. Masalah :
Pengkajian :

Makassar, .............................. 202

Dibuat oleh, Diperiksa dan disetujui oleh,

(___________________________) (_______________________________)
Coass Supervisor

Diperiksa dan disetujui oleh,

( dr. Prema Hapsari Hidayati, Sp.PD )

FOLLOW UP PASIEN

Tanggal SOA PLANNING

 Makassar, .............................. 20...
Dibuat oleh, Diperiksa dan disetujui oleh,

(____________________________) (_______________________________)
Coass Supervisor