RSUD Dr.Adnaan WD No.

RM :
Nama :
PAYAKUMBUH Umur :
Alamt :
ASESMEN MEDIS RAWAT INAP
Ruang :
PASIEN BEDAH
DPJP : PPJP :
Diisi oleh Dokter
Tanggal :
1. STATUS GENERAL
A. ANAMNESA
1. Keluhan Utama
.......................................................................................................................
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.......................................................................................................................
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2. Riwayat Penyakit Dahulu
.......................................................................................................................
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3. Riwayat Penyakit Sekarang
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4. Riwayat Penyakit Keluarga
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B. PEMERIKSAAN FISISK
1. Vital Sign :
2. Cranium .......................................................................................................
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.......................................................................................................................
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3. Leher .....................................................................................................
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.......................................................................................................................
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4. Thorax .....................................................................................................
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5. Abdomen ......................................................................................................
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6. Gentalia ......................................................................................................
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7. Extremitas
a. Ex.
Atas ..........................................................................................................
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..................................................................................................................
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b. Ex.
Bawah .......................................................................................................
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2. STATUS LOKALIS
3. DIAGNOSIS PENUNJANG
1. Laboratorium .......................................................................................................
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..............................................................................................................................
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2. Radiologi ..........................................................................................................
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..............................................................................................................................
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3. ECG ..........................................................................................................
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4. Lain
lain .....................................................................................................................
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4. DIAGNOSIS
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5. TERAPI
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Nama
dan Tanda tangan DPJP

(
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 RSUD Dr.Adnaan WD No. RM :
Nama :
PAYAKUMBUH Umur :
Alamt :
ASESMEN MEDIS RAWAT INAP
Ruang :
PASIEN SYARAF
DPJP : PPJP :
Diisi oleh Dokter
Tanggal :
I. ANAMNESA
1. Keluhan Utama
.......................................................................................................................
......................
.......................................................................................................................
......................
2. Riwayat Penyakit Dahulu
.......................................................................................................................
......................
.......................................................................................................................
......................
3. Riwayat Penyakit Sekarang
.......................................................................................................................
......................
.......................................................................................................................
......................
4. Riwayat Penyakit Keluarga
.......................................................................................................................
......................
.......................................................................................................................
......................

II. PEMERIKSAAN FISISK

a)STATUS INTERNIS
1. Vit al Sign :
2. Cranium .......................................................................................................
.....................
.......................................................................................................................
......................
3. Leher .....................................................................................................
.......................
.......................................................................................................................
......................
4. Thorax .....................................................................................................
......................
.......................................................................................................................
......................
5. Abdomen ......................................................................................................
......................
.......................................................................................................................
......................
6. Extremitas ....................................................................................................
......................

b)STATUS
PSIKATRIS : .....................................................................................
...................
c) STATUS NEOROLOGIS
Kepala
Pupil : Diameter : Isokor An isokor
Reflek cahaya :
Reflek Kornea :
Nervus Cranialis (I-
XII) ............................................................................................................
...........................................................................
.................................
 ...........................................................................
.................................
Leher
Kaku
Kuduk :........................................................................................
....................
Meninggak
Sign :..................................................................................................
..........
Brudzinki I-
IV :.................................................................................................
...........
Doll's eye
phenomena :..................................................................................................
..........

Vertebra ........................................................................................................
..........................
Exstremitas
Gerakan dan kekuatan:

Reflek fisiologis :
III. DIAGNOSIS PENUNJANG
1. Laboratorium .......................................................................................................
.....................
..............................................................................................................................
.....................
2. Radiologi ..........................................................................................................
......................
..............................................................................................................................
.....................
3. ECG ..........................................................................................................
......................
4. Lain
lain .....................................................................................................................
...........
..............................................................................................................................
.....................

IV. DIAGNOSIS
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..............................................................................................................................
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V. TERAPI
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Nama
dan Tanda tangan DPJP

(
)
 RSUD Dr.Adnaan WD No. RM :
Nama :
PAYAKUMBUH Umur :
Alamt :
ASESMEN MEDIS RAWAT INAP
Ruang :
PASIEN THT
Jenis Ruang :.................................................
kelamin :................................................... ............
. Kelas :.................................................
Tgl ............
Masuk :................................................ PPJP : .................................................
.... ............
DDJP :.........................................
...........
Diisi oleh Dokter
Tanggal :
1. STATUS GENERAL
A. ANAMNESA
1. Keluhan Utama
.......................................................................................................................
......................
.......................................................................................................................
......................
2. Riwayat Penyakit Dahulu
.......................................................................................................................
......................
.......................................................................................................................
......................
3. Riwayat Penyakit Sekarang
.......................................................................................................................
......................
.......................................................................................................................
......................
4. Riwayat Penyakit Keluarga
.......................................................................................................................
......................
.......................................................................................................................
......................

B. PEMERIKSAAN FISISK
1. Vital Sign :
2. Cranium .......................................................................................................
.....................
.......................................................................................................................
......................
3. Leher .....................................................................................................
.......................
.......................................................................................................................
......................
4. Thorax .....................................................................................................
......................
.......................................................................................................................
......................
5. Abdomen ......................................................................................................
......................
.......................................................................................................................
......................
 6. Gentalia ......................................................................................................
......................
.......................................................................................................................
......................
7. Extremitas
a. Ex.
Atas .........................................................................................................
...............
..................................................................................................................
....................
b. Ex.
Bawah .......................................................................................................
..............
..................................................................................................................
....................
2. STATUS LOKALIS

a. Telinga Telinga Luar Daun Telinga :

Liang Telinga :
Telinga Tengah Membran tympani :
Audio Metri
b. Hidung Hidung Luar Cavum nasi :
Concae :
Septum nasi :
Concae Interior :
c. Tenggorokan Tonsil
Daerah Posterior
farinx
Larinx Epiglotis :
Pita Suara :
3. DIAGNOSIS PENUNJUANG

D.DIAGNOSIS
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E. TERAPI

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 Nama dan Tanda Tangan DPJP

(
)

RSUD Dr.Adnaan WD No. RM :

Nama :
PAYAKUMBUH Umur :
Alamt :
ASESMEN MEDIS RAWAT INAP
Ruang :
PASIEN BEDAH
DPJP : PPJP :
Diisi oleh Dokter
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. Genetalia .........................................................................................
.......................................
........................................................................................................
........................................
7. Exstremitas
a. Ex.
Atas .............................................................................................
................................
b. Ex.Bawah .....................................................................................
.....................................
....................................................................................................
......................................
C. DIAGNOSIS PENUNJANG
1. Laboratorium ..................................................................................
......................................
........................................................................................................
.......................................
 2. Radiologi .........................................................................................
.....................................
D.DIAGNOSIS

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E. TERAPI

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Nama dan Tanda Tangan DPJP

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