Format Asesmen Medis Penyakit Dalam RAWAT JALAN

PEMERINTAH KOTA SIBOLGA

RSU DR. FERDINAND LUMBANTOBING

ASESMEN MEDIS RAWAT JALAN PASIEN PENYAKIT DALAM

NO.RM NAMA UMUR ....... ALAMAT

: : .................................. : ........................... : ..................................

PPJP : ........................................................... :............................................................ Di isi oleh Dokter

DPJP :.....................................................................

TANGGAL : :................................ A. ANAMNESA 1. Keluhan Utama : .............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. 2. Riwayat Penyakit Dahulu : .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 3. Riwayat Penyakit Sekarang : .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 4. Riwayat Penyakit Keluarga : .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. B. PEMERIKSAAN FISIK. 1. Vital Sign : .............................................................................................................................................. .............................................................................................................................................. 2. Cranium : .............................................................................................................................................. .............................................................................................................................................. 3. Leher : .............................................................................................................................................. .............................................................................................................................................. 4. Thorax : .............................................................................................................................................. ..............................................................................................................................................

5. Abdomen :................................................................................................................................ .................................................................................................................................................. .................................................................................................................................................. 6. Genitalia : ............................................................................................................................... .................................................................................................................................................. .................................................................................................................................................. 7. Extremitas : a. Ext. Atas : ............................................................................................................................ .................................................................................................................................................. .................................................................................................................................................. b. Ext. Bawah : ......................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... C. DIAGNOSTIK PENUNJANG. 1. Laboratorium :........................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... 2. Radiologi : ................................................................................................................................ ................................................................................................................................................... ................................................................................................................................................... 3. USG................................................................................................................................ ................................................................................................................................................... ................................................................................................................................................... 4. EKG................................................................................................................................ ................................................................................................................................................... ................................................................................................................................................... D. DIAGNOSA BANDING: ................................................................................................................................ ................................................................................................................................................... ................................................................................................................................................... E. DIAGNOSA KERJA : E. THERAPI. : .................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... Dokter Penanggung Jawab Pasien

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