LABEL IDENTITAS PASIEN

ASSESMEN AWAL RAWAT JALAN PENYAKIT DALAM

Beri Tanda ( ) pada kolom yang sesuai

ASSESMEN MEDIS

I. ANAMNESA
1. Keluhan Utama (mulai, lama, pencetus) :
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2. Riwayat penyakit sekarang :
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3. Riwayat penyakit dahulu (termasuk riwayat operasi) :
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4. Riwayat penyakit dalam keluarga :
DM Hipertensi TBC Asthma Hepatitis Jantung
Kelainan darah TAK Lain-lain____________________________

5. Riwayat alergi : a. Obat Tidak Ya, sebutkan:______________________

b. Makanan Tidak Ya, sebutkan :______________________
c. Lain-lain : ______________________________________

II. PEMERIKSAAN UMUM / FISIK

1. Keadaan umum : Tampak tidak sakit Tampak sakit ringan
Tampak sakit sedang Tampak sakit berat
2. Kesadaran : Kompos mentis Apatis Somnolen Sopor
Soporocoma Koma
3. GCS : E : _____________ M : ____________ V : ___________
4. TTV : S_____ N______ Rr_____ SpO2 _______ TD __________
5. Cranium
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6. Leher
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 7. Thorax
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8. Abdomen
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9. Genetalia
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10. Extremitas
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III. Pemeriksaan status generalis & status lokalis (inspeksi, palpasi, perkusi, dan auskultasi)

IV. Pemeriksaan penunjang:

Radiologi Lab USG EKG Lain-lain________________
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V. Status Gizi
Indikator Penilaian Malnutrisi
1. Apakah Indeks Masa Tubuh (IMT) < 18.5 kg/m atau 25 kg/m ? Ya Tidak
Cara menghitung IMT = BB / TB (m2)
2. Apakah pasien kehilangan berat badan 5% dalam waktu 3 bulan terakhir ? Ya Tidak
3. Apakah asupan makan pasien kurang dalam 1 minggu terakhir ? Ya Tidak
4. Apakah pasien menderita penyakit yang berat ? Ya Tidak
 Hasil :

Tidak Berisiko (Tidak ditemukan jawaban YA)

Berisiko ringan (Ditemukan jawaban YA = 1)
Diberitahukan pada dietisen : Tanggal..........................Pukul.......................
Berisiko Tinggi (Ditemukan jawaban YA lebih dari 1)
Diberitahukan kepada Dokter Spesialis Gizi klinik : Tanggal......................Pukul....................

VI. Diagnosa
1. Diagnosa kerja :
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2. Diagnosa banding :
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VII. Penatalaksanaan / perencanaan pelayanan : (Terapi, tindakan, konsultasi, pemeriksaan

penunjang lanjutan, edukasi dll )
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Diisi oleh Dokter yang melakukan Tanda tangan Dokter

pemeriksaan/pengkajian
Tanggal :
Waktu selesai/pukul :