Edit Laporan

Tgl

Jam

ALERGI

Sumber Data :

Judul Penilaian Nyeri

Skala nyeri

Tools :

Wong Baker Faces

Lama nyeri

Wong Baker Faces (Dewasa dan Anak lebih dari 3 Tahun)

NUMERIK

Numerik (Usia 10 Tahun Keatas)

Nyeri Hilang Dengan

Judul Anamnesa

Keluhan Utama

Batuk

Batuk Darah

Sesak nafas

Dahak

Nyeri dada

Lain-Lain

Keluhan Tambahan

Demam

Keringat malam

Nafsu makan/ BB menurun

Badan / Lemah

Lain-Lain

RIWAYAT PENYAKIT DAHULU DAN RIWAYAT PENGOBATAN

Kebiasaan

Anamnesa keluarga

Pemeriksaan fisik

TANDA-TANDA VITAL

Status Gizi

Kepala

Mata

THT

Leher

Thoraks

Pulmo

Inspeksi

Palpasi

Perkusi

Auskultasi

Suara tambahan

Lain-Lain

Cor

S1 , S2

Murmur

Abdomen

Nyeri tekan

Hepar

Lien

Lain-Lain

Ekstremitas

HASIL PEMERIKSAAN PENUNJANG SEBELUMNYA (Laboratorium , EKG, X-Ray dan Lain-lain)

DIAGNOSA KERJA

Diagnosa Utama

Diagnosa Tambahan

DIAGNOSA BANDING

TINDAKAN

Diagnosa Banding

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 <td width="327" nowrap="" colspan="2" rowspan="2" style="width:245.0pt;border:solid windowtext 1.0pt;
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:
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 color:black;mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:
 EN-ID">RENCANA TATALAKSANA<o:p></o:p>
 </td>
 <td width="339" rowspan="2" style="width:254.2pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:
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 color:black;mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:
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 </td>
 <td style="mso-cell-special:placeholder;border:none;padding:0cm 0cm 0cm 0cm" width="2"> </td>
 
 <td style="height:20.4pt;border:none" width="0" height="34"></td>
 
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:"Times New Roman";
 mso-hansi-font-family:Calibri;mso-bidi-font-family:Calibri;color:black;
 mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:EN-ID">1.
 Edukasi<o:p></o:p>
 </td>
 <td width="339" rowspan="3" style="width:254.2pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:
 "Times New Roman";mso-hansi-font-family:Calibri;mso-bidi-font-family:Calibri;
 color:black;mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:
 EN-ID">  □Ya(Isiedukasiterlampir          □Tidak<o:p></o:p>
 </td>
 <td width="2" style="width:1.8pt;padding:.75pt 5.4pt 0cm 5.4pt;height:14.4pt"></td>
 
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 <td width="327" nowrap="" colspan="2" rowspan="2" valign="top" style="width:245.0pt;
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:"Times New Roman";
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 mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:EN-ID">2. Pemeriksaan
 Penunjang Lanjutan (Diagnostik)<o:p></o:p>
 </td>
 <td width="339" nowrap="" rowspan="2" valign="bottom" style="width:254.2pt;border-top:
 none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:"Times New Roman";
 mso-hansi-font-family:Calibri;mso-bidi-font-family:Calibri;color:black;
 mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:EN-ID">3.
 Edukasi<o:p></o:p>
 </td>
 <td width="339" nowrap="" rowspan="2" valign="bottom" style="width:254.2pt;border-top:
 none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:
 "Times New Roman";mso-hansi-font-family:Calibri;mso-bidi-font-family:Calibri;
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 </td>
 <td width="2" style="width:1.8pt;padding:.75pt 5.4pt 0cm 5.4pt;height:14.4pt"></td>
 
 <td style="height:14.4pt;border:none" width="0" height="24"></td>
 
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 <td width="128" nowrap="" rowspan="3" style="width:96.0pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:"Times New Roman";
 mso-hansi-font-family:Calibri;mso-bidi-font-family:Calibri;color:black;
 mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:EN-ID">4. Nyeri<o:p></o:p>
 </td>
 <td width="199" nowrap="" rowspan="3" valign="bottom" style="width:149.0pt;border-top:
 none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:
 "Times New Roman";mso-hansi-font-family:Calibri;mso-bidi-font-family:Calibri;
 color:black;mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:
 EN-ID">( Khusus Nyeri Sedang - Berat<o:p></o:p>
 </td>
 <td width="339" nowrap="" rowspan="3" valign="bottom" style="width:254.2pt;border-top:
 none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:
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 color:black;mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:"Times New Roman";
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 mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:EN-ID">5. Terapi<o:p></o:p>
 </td>
 <td width="199" rowspan="3" style="width:149.0pt;border-top:none;border-left:
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:"Times New Roman";
 mso-hansi-font-family:Calibri;mso-bidi-font-family:Calibri;color:black;
 mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:EN-ID">Non
 farmakologis :<o:p></o:p>
 </td>
 <td width="339" nowrap="" rowspan="3" valign="bottom" style="width:254.2pt;border-top:
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:
 "Times New Roman";mso-hansi-font-family:Calibri;mso-bidi-font-family:Calibri;
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:"Times New Roman";
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 mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:EN-ID">Farmakologis<o:p></o:p>
 </td>
 <td width="339" nowrap="" rowspan="5" valign="bottom" style="width:254.2pt;border-top:
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:
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 <td width="327" colspan="2" rowspan="2" style="width:245.0pt;border:solid windowtext 1.0pt;
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:"Times New Roman";
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 mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:EN-ID">6.
 Tindakan<o:p></o:p>
 </td>
 <td width="339" nowrap="" rowspan="2" valign="bottom" style="width:254.2pt;border-top:
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:
 "Times New Roman";mso-hansi-font-family:Calibri;mso-bidi-font-family:Calibri;
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 mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:EN-ID">7. Konsul<o:p></o:p>
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 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:
 "Times New Roman";mso-hansi-font-family:Calibri;mso-bidi-font-family:Calibri;
 color:black;mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:
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 mso-hansi-font-family:Calibri;mso-bidi-font-family:Calibri;color:black;
 mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:EN-ID">8.
 Rencana Pemulangan<o:p></o:p>
 </td>
 <td width="339" rowspan="4" style="width:254.2pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:.75pt 5.4pt 0cm 5.4pt;
 height:14.4pt">
 <span style="mso-ascii-font-family:Calibri;mso-fareast-font-family:"Times New Roman";
 mso-hansi-font-family:Calibri;mso-bidi-font-family:Calibri;color:black;
 mso-font-kerning:0pt;mso-ligatures:none;mso-fareast-language:EN-ID">LamaRawatanhari                                                                             
 Alat Bantu Pulang  :    □ Perlu . . . . . . . .                                                                                           
 
                                       
 □Tidak Perlu <o:p></o:p>
 </td>
 <td width="2" style="width:1.8pt;padding:.75pt 5.4pt 0cm 5.4pt;height:14.4pt"></td>
 
 <td style="height:14.4pt;border:none" width="0" height="24"></td>
 
 </tr>
 <tr style="mso-yfti-irow:25;height:14.4pt">
 <td width="2" nowrap="" valign="bottom" style="width:1.8pt;padding:.75pt 5.4pt 0cm 5.4pt;
 height:14.4pt"></td>
 
 <td style="height:14.4pt;border:none" width="0" height="24"></td>
 
 </tr>
 <tr style="mso-yfti-irow:26;height:14.4pt">
 <td width="2" nowrap="" valign="bottom" style="width:1.8pt;padding:.75pt 5.4pt 0cm 5.4pt;
 height:14.4pt"></td>
 
 <td style="height:14.4pt;border:none" width="0" height="24"></td>
 
 </tr>
 <tr style="mso-yfti-irow:27;mso-yfti-lastrow:yes;height:14.4pt">
 <td width="2" nowrap="" valign="bottom" style="width:1.8pt;padding:.75pt 5.4pt 0cm 5.4pt;
 height:14.4pt"></td>
 
 <td style="height:14.4pt;border:none" width="0" height="24"></td>
 
 </tr>
</tbody></table>

<o:p> </o:p>

Edukasi

Alat Bantu Pulang

PENGKAJIAN AWAL MEDIS RAWAT INAP PENYAKIT PARU