Format Status RM IGD-New.1

)uma0 Saki% Is1am Si%i Dengan Ridho ALLAH SWT, Kesehatan Anda Adalah )a0ma0 Tujuan Kami 

INSTA&ASI 'A(AT DA)*)AT +I'D, No.R$am M$dis

: B/&

IDENTITAS TAMBAHAN PASIEN Nama Orang tua(ibu Kandung) : ..………………………………… ..…………………………………………………………… ………………………… Nama Nama Pasi$ asi$n n : No. KTP/SIM/PASPOR(WNA)* : S%a%us ……………………………………………………………………………………………………………………… Pem$a.aran Agama* : Isam / !indu / "ud#a / Krist$n :………………………… / %ain&ain :…………………….. *mum : Aamat Ruma# : ……………………………………………………………………………………………… …………………………………………… ………………………………………………………………………………………………. ……………………………………………... .………………………………………… .…………………… …………………………………………… ………………………………………..T ………………..T$$'on/!P $$'on/!P : BPS : …………………………………. In0ea1%0 : $sa / K$ura#an / K$amatan : P!S : ……………………………………………………………………………………………………………………. Kota / Kabu'at$n : ……………………………………………………………………………………………… …………………………………………… …………………………………………………………………………………………… ………………………………………… Pro'insi / N$gara (WNA) : ……………………………………………………………………………………………… …………………………………………… ……………………………………………………………………………….. …………………………….. P$$r+aan : ……………………………………………………………………………………………… …………………………………………… ……………………………………………………………………………………………………… ……………………………………………………..  Tangga  Tangga Masu Masu : #ari ……. / buan …… / ta#un ta#un ……. ,am Masu : ……………-ib  ,$nis Kun+ungan* Kun+ungan* : atang atang S$ndiri / Ru+uan Ru+uan / Kiriman Kiriman  dari: dari: RS / Pus$smas Pus$smas / ot$r / %ain&ain : …………………………………. P$ngantar : Nama ……............................... …….............. .................................. ....................... ...... Status* : K$uarga / Poisi / %ain&ain : ……………………………………………. Aamat …………………………………………… ……………………… ……………………………… ………… T$$'on/!P : ………………………………………………………………………………………….

Anamnesis

ATS 2 " ATS 2 Ri-aat '$nait................. '$nait............................. ........................ ........................ ......................... ......................... ........................ ........................ ..................................... ......................... : 3 Ri-aat a$rgi: ATS 2 Pemeriksaan Fisik 4 2/mnt1 K$sadaran : Tanda 0ita(0S) : T: mm!g1 N: 2/mnt1 P: •

K$u#an

:

•

•

S:

3

41 Sat.O 5 : 6 74S (89&) : K$'aa : …………………………………………….. Mata : ………………………………………………. .

"ibir : ……………………………………………… … Muut : ……………………………………………… 7igi : ………………………………………………. ……………………………………………… …. . %$#$r:  T$inga  T$inga : …………………………………………….. …………………………………………….. ada ada : ...... ......... ...... ...... ...... ...... ....... ........ ........ .... !idung :  ,antung..................................: ……………………………………………..  ,antung..................................: ................................. Paru.......................................:

Pemeriksaan Pemeriksaan Penunjang / Code ICD-9 CM : %aboratorium : %aboratorium  : ;47

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

Radioogi

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

K#usus/

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

Diagnosis !erja / Code ICD "# : Diagnosis Banding / Code ICD "# : Pengo$a%an

..................................... Abdom$n...............................: ............................... !$'ar.............. !$'ar........................... .......................: ..........: %i$n: ..................................... 7in+a.....................................: K$mauan...............................: ;str$mitas ;str$mitas Atas : .................   …………………………. ;str$mitas "a-a# : ……………………….. ………………………..

Tindakan / ICD-9 CM :

Ska1a N.eri  Tanda Siang)

WONG BAKER FAE RAT!NG SALE AND N"#ER! SALE * ("$ri

S%a%us &oka1is &uka 8. R$gio : ......................................................  ,$nis ua...........................: ..........................<uran !$matoma / N$ri t$an / N$ri sumbu Kr$'itasi / =untio a$sa / Ru'tur t$ndon 5. R$gio : ......................................................  ,$nis ua...........................: ..........................<uran !$matoma / N$ri t$an / N$ri sumbu Kr$'itasi / =untio a$sa / Ru'tur t$ndon . %ain&ain :....................................................... ........................................................ ........................................................ ("ia '$ru tamba#an %am'iran Status %oais)

!onsu1 Dok%er / DPP : +Sis%em SBA),  ,am Konsu :……………...-ib  ,a-aban Konsu :

Dok%er !onsu1en/DPP

(………………………………………………) St$m'$1Tanda Tangan dan Nama ,$as

Cara !e1uar I'D 8.  ,am K$uar 5. Ruang Ra-atan . Puang

: …………-ib : ................................ M$noa di ra-at / : Puang "ai /

P$rmintaan Pasi$n atau K$uarga /

Kar$na "iaa >. iru+u $

Aasan 9. Sarana/Trans'ortasi ?. M$ningga @. Kontro <ang

: .......................................  T$m'at '$nu# / : =asiitas tida ada :

"$r+aan / Kursi Roda / "ranar / : ……….…-ib : ………………………………………………….

)esume !ondisi !e1uar I'D :

Ambuan$ /

%ain&ain :

Dok%er

 aga I'D

(…………………………………………………………………) St$m'$1Tanda Tangan dan Nama  ,$as

 Pera5a% aga I'D

(………………………………………………….) St$m'$1 Tanda Tangan dan Nama  ,$as Beri tanda 

*Pilih Salah Satu