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Nama Pasien Lengkap

Tanggal Lahir Pasien

Jenis Kelamin Pasien

No Rekam Medis

Tanggal

Jam

ALERGI

Sumber Data

Penilaian Nyeri (Pengkajian Awal Medis)

Nyeri                    :  (         
)   tidak    (         
)   ya <o:p></o:p>Skala nyeri          :………………(Intensitas 0 - 10)<o:p></o:p>Karakteristik       :………………………………<o:p></o:p>Lokasi                 :………………………….........<o:p></o:p>Durasi                  : …………………………...........<o:p></o:p>

<span lang="IN" style="font-size:10.0pt;line-height:115%;font-family:"Times New Roman","serif";
mso-fareast-font-family:Calibri;mso-fareast-theme-font:minor-latin;mso-ansi-language:
IN;mso-fareast-language:EN-US;mso-bidi-language:AR-SA">Frekuensi             : ...….  x/hari 
(crescendo/decrescendo)<span lang="IN" style="font-size:10.0pt;line-height:115%;font-family:"Times New Roman","serif";
mso-fareast-font-family:Calibri;mso-fareast-theme-font:minor-latin;mso-ansi-language:
IN;mso-fareast-language:EN-US;mso-bidi-language:AR-SA"> Nyeri hilang, dengan :[  ] Minum Obat[  ] Istirahat     [  ] Mendengarkan musik[  ] Berubah posisi tidur[  ] Lain-lain, sebutkan ……………………………<span lang="IN" style="font-size:10.0pt;line-height:115%;font-family:"Times New Roman","serif";
mso-fareast-font-family:Calibri;mso-fareast-theme-font:minor-latin;mso-ansi-language:
IN;mso-fareast-language:EN-US;mso-bidi-language:AR-SA">

Keluhan Utama

Telaah Riwayat Penyakit Sekarang

Riwayat Penyakit Dahulu dan Riwayat Pengobatan

Riwayat penyakit keluarga

Riwayat Pekerjaan, Sosial, Ekonomi, Psikologi dan Kebiasaan

Tanda-tanda Vital

Pemeriksaan Fisik (Pengkajian Awal Medis)

<table class="table table-bordered"><tbody><tr><td style="text-align: center; ">No</td><td style="text-align: center; ">Anggota Tubuh</td><td style="text-align: center; ">Normal (beri tanda <span lang="IN" style="font-size:11.0pt;line-height:
115%;font-family:"Times New Roman","serif";mso-fareast-font-family:Calibri;
mso-fareast-theme-font:minor-latin;mso-bidi-theme-font:minor-bidi;mso-font-width:
61%;mso-ansi-language:IN;mso-fareast-language:EN-US;mso-bidi-language:AR-SA;
mso-no-proof:yes">√)</td><td style="text-align: center; ">Abnormal (jelaskan)</td></tr><tr><td style="text-align: center; ">1</td><td>Kepala</td><td> </td><td> </td></tr><tr><td style="text-align: center; ">2</td><td>Mata</td><td> </td><td> </td></tr><tr><td style="text-align: center; ">3</td><td>Leher</td><td> </td><td> </td></tr><tr><td style="text-align: center;">4</td><td>THT</td><td> </td><td> </td></tr><tr><td style="text-align: center; ">5</td><td>Mulut</td><td> </td><td> </td></tr><tr><td style="text-align: center; ">6</td><td>Jantung</td><td> </td><td> </td></tr><tr><td style="text-align: center; ">7</td><td>Paru</td><td> </td><td> </td></tr><tr><td style="text-align: center; ">8</td><td>Abdomen</td><td> </td><td> </td></tr><tr><td style="text-align: center; ">9</td><td>Genitalia</td><td> </td><td> </td></tr><tr><td style="text-align: center; ">10</td><td>Extremitas</td><td> </td><td> </td></tr></tbody></table>

Diagnosa Kerja :

Diagnosa Utama        : ...............................................................................Diagnosa Tambahan : ...............................................................................Diagnosa Banding      : ............................................................................... <table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="514" style="background-color: rgb(249, 247, 243); width: 385.8pt;"><tbody><tr style="height: 14.4pt;"><td width="256" nowrap="" colspan="2" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border: 1pt solid windowtext; height: 14.4pt;">RENCANA TATALAKSANA<o:p></o:p></td><td width="256" nowrap="" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border-top: 1pt solid windowtext; border-right: 1pt solid windowtext; border-bottom: 1pt solid windowtext; border-image: initial; border-left: none; height: 14.4pt;">INTRUKSI (DENGAN TARGET TERUKUR)<o:p></o:p></td><td width="2" style="padding: 0cm; border: none;"> </td><td width="0" height="24" style="height: 14.4pt; border: none;"></td></tr><tr style="height: 20.4pt;"><td width="256" nowrap="" colspan="2" rowspan="2" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border-right: 1pt solid windowtext; border-bottom: 1pt solid windowtext; border-left: 1pt solid windowtext; border-image: initial; border-top: none; height: 20.4pt;">1. Edukasi</td><td width="256" rowspan="2" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border-top: none; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid windowtext; height: 20.4pt;">[  ] Ya (isi edukasi terlampir)     [  ] Tidak<o:p></o:p></td><td width="2" style="padding: 0cm; border: none;"> </td><td width="0" height="34" style="height: 20.4pt; border: none;"></td></tr><tr style="height: 14.4pt;"><td width="2" nowrap="" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 1.8pt; height: 14.4pt;"></td><td width="0" height="24" style="height: 14.4pt; border: none;"></td></tr><tr style="height: 14.4pt;"><td width="256" colspan="2" rowspan="2" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border-right: 1pt solid windowtext; border-bottom: 1pt solid windowtext; border-left: 1pt solid windowtext; border-image: initial; border-top: none; height: 14.4pt;">2. Pemeriksaan Penunjang  (Diagnostik) Lanjutan<o:p></o:p></td><td width="256" nowrap="" rowspan="2" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border-top: none; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid windowtext; height: 14.4pt;"> <o:p></o:p></td><td width="2" style="padding: 0.75pt 5.4pt 0cm; width: 1.8pt; height: 14.4pt;"></td><td width="0" height="24" style="height: 14.4pt; border: none;"></td></tr><tr style="height: 14.4pt;"><td width="2" nowrap="" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 1.8pt; height: 14.4pt;"></td><td width="0" height="24" style="height: 14.4pt; border: none;"></td></tr><tr style="height: 14.4pt;"><td width="256" colspan="2" rowspan="2" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border-right: 1pt solid windowtext; border-bottom: 1pt solid windowtext; border-left: 1pt solid windowtext; border-image: initial; border-top: none; height: 14.4pt;">3. Diet<o:p></o:p></td><td width="256" nowrap="" rowspan="2" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border-top: none; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid windowtext; height: 14.4pt;"> <o:p></o:p></td><td width="2" style="padding: 0.75pt 5.4pt 0cm; width: 1.8pt; height: 14.4pt;"></td><td width="0" height="24" style="height: 14.4pt; border: none;"></td></tr><tr style="height: 14.4pt;"><td width="2" nowrap="" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 1.8pt; height: 14.4pt;"></td><td width="0" height="24" style="height: 14.4pt; border: none;"></td></tr><tr style="height: 14.4pt;"><td width="256" colspan="2" rowspan="2" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border-right: 1pt solid windowtext; border-bottom: 1pt solid windowtext; border-left: 1pt solid windowtext; border-image: initial; border-top: none; height: 14.4pt;">4. Nyeri (Khusus nyeri sedang-berat<o:p></o:p></td><td width="256" nowrap="" rowspan="2" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border-top: none; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid windowtext; height: 14.4pt;"> <o:p></o:p></td><td width="2" style="padding: 0.75pt 5.4pt 0cm; width: 1.8pt; height: 14.4pt;"></td><td width="0" height="24" style="height: 14.4pt; border: none;"></td></tr><tr style="height: 14.4pt;"><td width="2" nowrap="" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 1.8pt; height: 14.4pt;"></td><td width="0" height="24" style="height: 14.4pt; border: none;"></td></tr><tr style="height: 14.4pt;"><td width="87" nowrap="" rowspan="5" style="padding: 0.75pt 5.4pt 0cm; width: 65.5pt; border-right: 1pt solid windowtext; border-bottom: 1pt solid windowtext; border-left: 1pt solid windowtext; border-image: initial; border-top: none; height: 14.4pt;">5. Terapi<o:p></o:p></td><td width="169" rowspan="3" style="padding: 0.75pt 5.4pt 0cm; width: 126.5pt; border-top: none; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid windowtext; height: 14.4pt;">Non farmakologis<o:p></o:p></td><td width="256" nowrap="" rowspan="3" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border-top: none; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid windowtext; height: 14.4pt;"> <o:p></o:p></td><td width="2" style="padding: 0.75pt 5.4pt 0cm; width: 1.8pt; height: 14.4pt;"></td><td width="0" height="24" style="height: 14.4pt; border: none;"></td></tr><tr style="height: 14.4pt;"><td width="2" nowrap="" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 1.8pt; height: 14.4pt;"></td><td width="0" height="24" style="height: 14.4pt; border: none;"></td></tr><tr style="height: 14.4pt;"><td width="2" nowrap="" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 1.8pt; height: 14.4pt;"></td><td width="0" height="24" style="height: 14.4pt; border: none;"></td></tr><tr style="height: 14.4pt;"><td width="169" nowrap="" rowspan="2" style="padding: 0.75pt 5.4pt 0cm; width: 126.5pt; border-top: none; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid windowtext; height: 14.4pt;">Farmakologis<o:p></o:p></td><td width="256" nowrap="" rowspan="2" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border-top: none; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid windowtext; height: 14.4pt;"> <o:p></o:p></td><td width="2" style="padding: 0.75pt 5.4pt 0cm; width: 1.8pt; height: 14.4pt;"></td><td width="0" height="24" style="height: 14.4pt; border: none;"></td></tr><tr style="height: 14.4pt;"><td width="2" nowrap="" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 1.8pt; height: 14.4pt;"></td><td width="0" height="24" style="height: 14.4pt; border: none;"></td></tr><tr style="height: 14.4pt;"><td width="256" nowrap="" colspan="2" rowspan="3" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border-right: 1pt solid windowtext; border-bottom: 1pt solid windowtext; border-left: 1pt solid windowtext; border-image: initial; border-top: none; height: 14.4pt;">6. Tindakan<o:p></o:p></td><td width="256" nowrap="" rowspan="3" valign="bottom" style="padding: 0.75pt 5.4pt 0cm; width: 192pt; border-top: none; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid windowtext; height: 14.4pt;"> </td></tr></tbody></table>

PENGKAJIAN AWAL MEDIS