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No. Register :.........................................................................

Jl.Prapat Kurung Selatan No.1 Surabaya No. RM :.........................................................................


Telp. (031) 3294801-03, Fax.031-3294804
Nama :.........................................................................
ASESMEN AWAL THT Ruang :...............................Umur...........L/P................
A. Anamnesa
a. Keluhan utama :.........................................................................................................
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b. Riwayat penyakit sekarang :.........................................................................................................
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c. Riwayat Penyakit dahulu :.........................................................................................................
d. Riwayat penyakit dalam keluarga :.........................................................................................................
e. Riwayat pekerjaan :.........................................................................................................
f. Riwayat tumbuh kembang :.........................................................................................................

B. Pemeriksaan Fisik
I. Generalis

Asesmen Awal THT


a. Kepala : normal tidak normal ........................................................
b. Mata : normal tidak normal ........................................................
c. THT : normal tidak normal ........................................................
d. Leher : normal tidak normal ........................................................
e. Mulut : normal tidak normal ........................................................
f. Jantung dan pembuluh darah : normal tidak normal ........................................................
g. Thoraks, Paru-Paru, Payudara : normal tidak normal ........................................................
h. Abdomen : normal tidak normal ........................................................
i. Kulit dan sistem limfatik : normal tidak normal ........................................................
j. Tulang belakang dan anggota tubuh : normal tidak normal ........................................................
k. Sistem Saraf : normal tidak normal ........................................................
l. Genitalia, anus dan rectum : normal tidak normal ........................................................
II. Lokalis
a. Inspeksi :

b. Palpasi :

c. Perkusi :

d. Auskultasi :

4/1/RM/2/14/RS.PHC-2013 REV.01
III. Diagnosa Sementara :

IV. Pemeriksaan Penunjang :

V. Therapi :

Asesmen Awal
C. Nyeri
0 Tidak nyeri 1-3 Nyeri ringan 4- 6 Nyeri sedang 7-10 Nyeri berat

Surabaya,.

Pengkajian Ulang :
1. 15 menit setelah intervensi obat injeksi
2. 1 jam setelah intervensi obat oral atau lainnya
3. 1 x / shift bila skor nyeri 1-3
4. Setiap 3 jam bila skor nyeri 4-6
5. Setiap 1 jam bila skor nyeri 7-10
6. Dihentikan bila skor nyeri 0
Surabaya.,Jam
Nama dan Tanda Tangan
Dokter

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4/1/RM/2/14/RS.PHC-2013 REV.01