RM/GD.00/REV.00/201 No. RM :
PUSKESMAS PESANTREN 1 KEDIRI Jl.Brigjen Pol. Imam Bakri Hp No.94 Kota Kediri Telp. (0354 !90355.
"EM#AR INSTA"ASI $A%AT DARURAT
Nama
: ............................................. ...................................................... .........
Nama KK
: ............................................. ...................................................... .........
Tgl. Lahir/Umur
: ............................................. ...................................................... .........
Alamat/ No. Hp
: ............................................. ...................................................... .........
• • •
: ............................................. ...................................................... .........
• •
UMUM !U !U"!#D# $" $"# N%N $"# & AM AMKE!DA
: : : : :
'ara ma(u)
: Data*g !+*,iri / Dia*tar %l+h : ......................................................... ....................................................................................... ...................................... ........
Ti-a ,i #GD
:
Triag+ : %l+h : Ko*, Ko*,i( i(ii :
Gaa Gaatt Daru Darura ratt
Daru Darura ratt T,) T,) Gaa Gaatt
T,) T,) Gaa Gaatt T,) T,) Daru Darura ratt
M+*i M+*i*g *gga gall
Dip+ri)(a ,r. &aga #GD : ,r. .................................................... .................................................... &+*i( trauma trauma 1. 2. 4. 5. 6.
: K+. K+. LL/ K+. K+ra/ K+ra/ K+. RT/ RT/ KDRT/ KDRT/ Lu)a "a)ar/ Gigita*/ #*to)(i)a(i/ #*to)(i)a(i/ Lai**a Lai**a ............. .............
&ala* Napa( $+r*apa(a* !ir)ula(i !ir)ula(i Di(a Di(a-i -ili lit t E7po(ur+
: ................................................. ................................................. immo-ilita( '(pi*+ : ............................................... ............................................... : ................................................. ................................................. 3l+) : .......................................................... ................................................................./m*t ......./m*t : T+*(i T+*(i : ............ ................. .......... ........ ... mmhg Na,i : .......... ............... .......... .......... .......... .......... .......... .......... .......... ...../m*t /m*t : G'! G'! : .... ...... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .. Lat+ Lat+ra ra(i (i : .... ...... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... : .............................................................. ............................................................................................ ............................................................ ......................................... ...........
ANAMNESA
K+luha* Utama
:
Riaat $+*a)it !+)ara*g
:
Riaat $+*a)it Dahulu
:
%-ato-ata*
:
Al+rgi
:
PEMERIKSAAN &ISIK 8N9 Normal
8A9 A-*ormal A-*ormal
"ila 8A9 "+ri $+*+la(a* N
1. 2. 4. 5. 6. . <. =. >. 10. 10. 11. 11.
K+pa K+pala la / a aah ah L+h+r / V. !+r;i)ali( THT Mata Da,a &a*tu*g $aruparu $au au,ara $+rut $+; $+;i( $+rium $+rium/r+) /r+)tum tum
A
PEMERIKSAAN &ISIK 8N9 Normal
12. 14. 15. 16.
8A9 A-*ormal
"ila 8A9 "+ri $+*+la(a*
Urog+*itali( A*ggota g+ra) ata( A*ggota g+ra) -aah $+m+ri)(aa* *+urologi(
PEMERIKSAAN PENUN'AN$
La-oratorium
:
Diag*o(a prim+r
:
Diag*o(a (+)u*,+r
:
T+rapi/ Ti*,a)a*
:
Ti*,a) la*ut
:
1. 2. 4. 5. 6. .
Dipula*g)a*? o*trol ,i : $oli Umum/ K#A/ $oli Gigi/ Lai**a................ %p*am+? Do)t+r a*g m+raat .................................................................. Diruu) )+ ................................................................................................... $ula*g pa)(a / m+*ola) ti*,a)a* : ............................................................. M+lari)a* ,iri M+*i*ggal. Tgl/&am : .......................... !+-a- )+matia* : ..........................
K+luar ,ari #GD am : .............................. 'atata* Lai*
: .....................................................................................................
Nama l+*g)ap ,a* ta*,a ta*ga* Do)t+r #GD
@,r. ................................................................ Tgl. ...............................................................
Bor+t a*g ti,a) p+rlu
$U!KE!MA! $E!ANTREN 1 KED#R#
&l."rig+* $ol. #mam "a)ri Hp No.>5 Kota K+,iri T+lp. @0465 >0466. KARTU KENDA"I
Tgl. Dit+rima
Tgl. Di(+rah)a* K+m-ali
Nama $a(i+*
No. RM
Alamat
K+ti,a)l+*g)apa* :
TTL
1. 2.
&+*i( K+lami*
4. 5.
Tgl. Ma(u)
6. .
Tgl. K+luar
<. =.
Lama Diraat
>
10.
K+la( $+raata*
Do)t+r a*g m+raat
K+p+rlua* : u*tu) )+l+*g)apa* p+*gi(ia* ,ata pa(i+*
$+tuga(
@.......................................
