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STATUS POMR
MAHASISWA PROGRAM PENDIDIKAN DOKTER SPESIALIS
PRODI ILMU PENYAKIT DALAM
FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN
PERIODE : ..................................................................
NOMOR URUT PASIEN: ......
No Reg. RS :…………………………..( RS ..................................................................... )
STATUS PASIEN : RAWAT JALAN / RAWAT INAP
Nama Lengkap :
Tanggal lahir :
Umur : tahun Jenis kelamin : L / P
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Alamat : Nomor telepon

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

Pendidikan : Etnis / Suku : Agama :

Nama Asisten No. CHS Tanggal Pemeriksaan

ANAMNESIS
Autoanamnesis Alloanamnesis
RIWAYAT PENYAKIT SEKARANG
Keluhan Utama : ______________________________________________________
Riwayat perjalanan penyakit :
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No.pasien........................... No.Medical record.................... Inisial peserta PPDSSp1............../tgl...................

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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 : ___________________________________________________________

DESKRIPSI UMUM
Kesan Sakit : ringan / sedang / berat
Gizi :
Berat Badan : …………… Kg; Tinggi badan : ……………… cm; IMT :
2
…………………Kg/m
TANDA VITAL
Kesadaran :
Nadi Frekuensi :…………………. / menit, Deskripsi :
Tekanan Darah Berbaring Duduk mmHg
o
Temperatur Aksilla : Rektal : C
Pernafasan Frekuensi :………………./ menit Deskripsi :
PEMERIKSAAN FISIK :
Kepala dan Leher
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Thorax Kiri Kanan
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No.pasien........................... No.Medical record.................... Inisial peserta PPDSSp1............../tgl...................

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________________________________________________________
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Jantung
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Paru-paru
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Abdomen
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Ekstremitas
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Rektum
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Status Lokalis

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No.pasien........................... No.Medical record.................... Inisial peserta PPDSSp1............../tgl...................

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________________________________________________________
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Pemeriksaan Penunjang
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No.pasien........................... No.Medical record.................... Inisial peserta PPDSSp1............../tgl...................

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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 :

No.pasien........................... No.Medical record.................... Inisial peserta PPDSSp1............../tgl...................

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3. Masalah :
Pengkajian :

4. Masalah :
Pengkajian :

5. Masalah :
Pengkajian :

6. Masalah :
Pengkajian :

Makassar, .............................. 20...

Dibuat oleh, Diperiksa dan disetujui oleh,

(____________________________) (_______________________________)
MPPDS Supervisor

No.pasien........................... No.Medical record.................... Inisial peserta PPDSSp1............../tgl...................