MR. 3a/BEDAH NON TRAUMA/R.I/C/2013
RSUP Dr. Wahidin Sudirohusodo Makassar Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818
PENGKAJIAN AWAL RAWAT INAP MEDIS BEDAH - NON TRAUMA Ruangan :
Tanggal
No. Rekam Medik Nama Lengkap Jenis Kelamin Tanggal Lahir Alamat Rujukan :
Ya, dari,
:
Jam :
: ................ ................. ............... ............... ................. ............... ................. ............. ................ ............... ............... .......... : ................ ................. ............... ............... ................. ............... ................. ............. ................ ............... ............... .......... : ................ ................. ............... ............. ................. ................ ................ ................ ................. ............... ............... ........ : ................ ................. ............... ............... ................. ............... ................. ............. ................ ............... ............... .......... : .................. ............................ ................... ................... .................... ..................... .................... ................... ................... ................... ................... ................... .................... ................... ................... ................... .................... .................. ....... RS ................... ....................... ....
Puskesmas ................... ........................ .....
Praktek ................. ............................ ...........
Lainnya ................... ............................. ............ ..
Diagnosa Rujukan ............... ............... ................. ............... ............... .................. ............... ............... ............... ................. ............... ... Tidak Dokter yang Memeriksa
Datang Sendiri
Diantar ………………………………………………… ..…. ..….
: ................ ............... ................. ......... Supervisor Supervis or jaga
: ................ ................. ............... ................. ...........
ANAMNESA Tanggal : Jam : 1. Keluhan Utama : ............... ................ ................. ................ ................. ............... ............. ............... ................. ................ ................. ........ 2. Riwayat Penyakit Sekarang : .............. ............... .................. ............... ................. ............... ............... ................ .............. .................. ....... ................................................................................................................................................................................................................... ................................................................................................................................................................................................................... ................................................................................................................................................................................................................... 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RSUP Dr. Wahidin Sudirohusodo Makassar Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818
PENGKAJIAN AWAL RAWAT INAP MEDIS BEDAH - NON TRAUMA ................................................................................................................................................................................................................... ................................................................................................................................................................................................................... ................................................................................................................................................................................................................... ................................................................................................................................................................................................................... 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MR. 3a/BEDAH NON TRAUMA/R.I/C/2013
RSUP Dr. Wahidin Sudirohusodo Makassar Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818
PENGKAJIAN AWAL RAWAT INAP MEDIS BEDAH - NON TRAUMA Nama Pasien :
No. Rekam Medis :
Tgl. Lahir :
Ruangan :
3. Riwayat Penyakit dahulu: Hipertensi
DM
PJK
Asma
Liver
Ginjal
TB Paru
Lain-lain ………………………………………………
Pernah Pernah dirawat
Tidak
Stroke
Ya,Kapan ………… Di mana …………………………… Diagnosis ……………………………
4. Riwayat Pengobatan (termasuk (termasuk obat yang sedang dikonsumsi) dikonsumsi) : Nama Obat
Dosis
Waktu Penggunaan
1. ……………………………………….
………………….………………….
………………………………………
2. ……………………………………….
……………………………………..
………………………………………
3. …………………………………........
………………….…...... ………………….… ......………….. …………..
………………………………………
4. …………………………………….…
……………………………….. ……………………………… ..…… ……
.………………………………………
5. Riwayat Penyakit Keluarga Hipertensi
Kencing Manis
Jantung
Asma
Lainnya …………………………………………………
PENILAIAN NYERI Nyeri
:
Tidak Ya: Lokasi: …………….……. Intensitas Intensit as …… Jenis
:
Skor : Skor : …… (Metode VAS/BPS/NIPS/FLACC)
Akut Kronis
TANDA-TANDA VITAL Keadaan Umum :
Baik
Sedang
Lemah
GCS : E….. E….... .. M…... M…. .... V…. V….….
Tindakan Resusitasi:
BB : ………… Kg
TB:……… cm
Tek. Darah: Darah: …………. mmHg, mmHg , Respirasi: …….. x/mnt,
Jelek,
Gizi :
Ya
Tidak
Baik
Kurang
Buruk
Nadi: …………. x/mnt Suhu Axila/Rektal: ………… OC/……………. OC
PEMERIKSAAN FISIS Mata : Anemis :
Tidak
Ada, Ikterus :
Udem Palpebrae :
Tidak
Tidak
Ada,
Pupil :
anisokor
Isokor, diameter ........../......... ........../........... mm,
Ada
THT :
Tonsil : …………………, …………………, Faring : ………………………, ……………………… , Lidah : ………………………., ………………………. , Bibir :…………...... :…………......…….. ……...................... ....................
Leher :
JVP : ………………….., ………………….. , Pembesaran Kelenjar Limfe: Thoraks : Cor :
Simetris
Tidak
Ada, .................. ............................. ................... .............. ...... Kaku kuduk :
Tidak
Ada
Asimetris: ............... ............... ................. ............... .................. ............... ............... ............... ......
S1/S2 S1/S2 …………………………….
Reguler
Ireguler, Ireguler , Murmur ................ ................ ................. ................ ......
Lain-lain : .............................................................................................................................................................................. Pulmo : Suara Nafas : ............... ................. ......, Ronchi : Wheezing Wheezi ng : Abdomen : Distended Distended : Peristaltik :
Normal
Nyeri Tekan :
Tidak
Tidak Tidak
Tidak
Ada ................ ................ ................. ............... ....
Ada, ............... ............... ................. ............... ............... .................. ............... ............. . Ada,
Meningkat
Meteorismus : menurun
Tidak Tidak ada,
Ada Asites:
Tidak
Ada
Ada, Lokasi : .................. ............... ................. ............... ............... ................. ...........
Hepar : .............. ................ ................. ..........., Lien : ................. ................ ............... .................. ............... ......... Extremitas : Lain-Lain:
Hangat
Dingin
Udem :
Tidak
Ada, ................ ................. .............. .............. .....
..............................................................................................................................................................
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RSUP Dr. Wahidin Sudirohusodo Makassar Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818
PENGKAJIAN AWAL RAWAT INAP MEDIS BEDAH - NON TRAUMA STATUS LOKALIS
HASIL PEMERIKSAAN PEMERIKSAAN PENUNJANG
DIAGNOSA 1.
....................................................................................................
2.
....................................................................................................
3.
....................................................................................................
4.
....................................................................................................
5.
....................................................................................................
TERAPI
RENCANA KERJA
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MR. 3a/BEDAH NON TRAUMA/R.I/C/2013
RSUP Dr. Wahidin Sudirohusodo Makassar Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818
PENGKAJIAN AWAL RAWAT INAP MEDIS BEDAH - NON TRAUMA Nama Pasien :
No. Rekam Medis :
Tgl. Lahir :
Ruangan :
HASIL PEMBEDAHAN
DIAGNOSA AKHIR
DISPOSISI Hidup :
Boleh pulang
Jam Keluar: ……………wita
Tanggal : ……………………………….
Kontrol polkinik :
Tidak
Ya,……………………….
Tanggal: ……………..,………………
Dirawat di ruang :
Intensif/ ICU
Lontara II B. Digestif
Lontara II B. Urologi
Lontara II B. Onkologi
Lontara II B. Ortopedi
Lontara III B. Saraf
Lontara II B. Anak
Ruang lain: …………………………. Mati:
Death on Arrival
Setelah resusitasi resusitas i
Kelas …………..
Jam ………………….. wita
Tanggal : ……………………………………………….
Penyebab Penyebab kematian : ……………………………………………… ......... REKOMENDASI REKOMENDASI (SARAN )
Yang Melakukan Pengkajian Tanggal / Jam : Nama Dokter :
CATATAN PENTING
Tanda tangan dokter
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