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MR.3a/BEDAH TRAUMA/R.

I/C/2013 MR
RSUP Dr. Wahidin Sudirohusodo Makassar
Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818

PENGKAJIAN AWAL RAWAT INAP MEDIS


BEDAH - TRAUMA

Ruangan : Tgl : Jam :

No. Rekam Medik : .....................................................................................................................................................................................


Nama Lengkap : .....................................................................................................................................................................................
Jenis Kelamin : .....................................................................................................................................................................................
Tanggal Lahir : .....................................................................................................................................................................................
Alamat : .....................................................................................................................................................................................
Rujukan : Ya, dari, RS ....................... Puskesmas ........................ Dr. ............................. Lainnya ...............................
Diagnosa Rujukan ...............................................................................................................................................................................

Tidak Datang Sendiri Diantar …………………………………………………..….

Dokter yang Memeriksa : ......................................................... Supervisor jaga : ............................................................................


ANAMNESA Tanggal : Jam :
1. Keluhan Utama : ......................................................................................................................................................................................
2. Riwayat Penyakit Sekarang : ....................................................................................................................................................................
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1/6
MR
RSUP Dr. Wahidin Sudirohusodo Makassar
Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818

PENGKAJIAN AWAL RAWAT INAP MEDIS


BEDAH - TRAUMA

3. Riwayat Penyakit dahulu:


Hipertensi DM PJK Asma Stroke
Liver Ginjal TB Paru Lain-lain ………………………………………………
Pernah dirawat Tidak Ya,Kapan …………… Di mana …………………… Diagnosis ……………………………………………..
4. Riwayat Pengobatan (termasuk obat yang sedang dikonsumsi)
Nama Obat Dosis Waktu Penggunaan
1. ………………………………………. ………………….…………………. . ………………………………………
2. ………………………………………. ……………………………………… ……………………………………….
3. …………………………………........ ………………….…......…………… ……………………………………….
4. …………………………………….… ………………………………..…… . .……………………………………….
5. Riwayat Penyakit Keluarga
Hipertensi Kencing Manis Jantung Asma Lainnya …………………………………………………

PENILAIAN NYERI TANDA-TANDA VITAL

Nyeri : Tidak Keadaan Umum : Baik Sedang Lemah Jelek,


Ya: Lokasi: …………….……. Intensitas …… Gizi : Baik Kurang Buruk
Jenis : Akut GCS : E….... M….... V….…. Tindakan Resusitasi: Ya Tidak
Kronis BB : ………… Kg TB:……… cm
Tensi: …………. mmHg, Nadi: …………. x/mnt
Skor : …… (Metode VAS/BPS/NIPS/FLACC) Respirasi: …….. x/mnt,
Suhu Axila/Rektal: ………… OC/……………. OC

INFORMASI PREHOSPITAL
Kecelakaan Lalu Lintas :  Pejalan kaki X ................................................
 Sepeda gayung X .................................................
 Sepeda motor X .................................................
 Mobil X ................................................. ICD X : .................................................
Kecelakaan lainnya : Jatuh ……. meter dari, Pohon Gedung Lainnya .................................................
Luka Tembak Luka Tusuk
Luka Hancur (crushed) Luka bakar
Lainnya, .............................................................
Mekanisme kecelakaan : Mobil : Pengemudi Penumpang
Memakai sabuk pengaman : Ya Tidak
Sepeda motor : Pengemudi Penumpang
Memakai helm : Ya Tidak
Pejalan kaki : Tertabrak, Mobil Sepeda motor Lainya, .......................
Tanggal kejadian : …… / ….. / .... , Pukul: ….. : ….. Wita Tempat kejadian : ………………………………………..

RIWAYAT AMPLE

Alergi :  Tidak Ada Ya ……………....................................................................

Medikasi :  Tidak Ada Ya……………................................................................

Penyakit lain / penyerta :  Tidak Ada Ya, ........................................................


Makanan terakhir, jam : …… : ….. Wita , Pengaruh NAPZA : Tidak Ya, jenis ...................................................................
Suntikan Anti Tetanus terakhir : .......................................

Hamil:  Tidak Ya: Umur kehamilan : .…. bulan Menstruasi terakhir : ........................................................................
Kejadian-kejadian yang lain : ................................................................

2/6
MR.3a/BEDAH TRAUMA/RI/C/2013 MR
RSUP Dr. Wahidin Sudirohusodo Makassar
Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818

PENGKAJIAN AWAL RAWAT INAP MEDIS


BEDAH - TRAUMA

Nama Pasien : No. Rekam Medis :

Tgl. Lahir : Ruangan :

TINDAKAN PREHOSPITAL

C-Spine Protection : Tidak Ya …………….. Airway device : Tidak  Ya .......................................................

IV Line : Tidak Ya……………... Medications : Tidak Ya .......................................................


Lain-lain :…………….

PRIMARY SURVEY TRAUMA SCORE


A. Airway A. Frekuensi Pernafasan
 Bebas  Tersumbat 10-25 4
Trachea di tengah: Ya  Tidak 25-35 3
 Resusitasi : …………………………..… >35 2
 Re-evaluasi : ……………………………..
<10 1
B. Breathing
0 0
 Dada simetris: Ya Tidak
 Sesak nafas : Ya  Tidak B. Usaha bernafas
 Respirasi ……….. x/mnt
Normal 1
 Krepitasi : Ya  Tidak
Dangkal 0
 Suara nafas:
- Kanan :  Ada :  Jelas  Menurun  Ronchi C. Tekanan darah
 Wheezing >89 mmHg 4
Tidak Ada 70-89 mmHg 3
Kiri :  Ada : Jelas Menurun Ronchi 50-69 mmHg 2
Wheezing 1-49 mmHg 1
 idak Ada
T 0 0
 Saturasi O2 : …………….. % D. Pengisian kapiler
pada: Suhu ruangan Nasal canule
<2 dtk 2
NRB Lainnya ………………….
 Assessment: ……. >2 dtk 1
 Resusitasi : ……….. Tidak ada 0
 Re-evaluasi : ………..
C. Circulation E. Glasgow Coma Score (GCS)
 Tensi : ……./……….mmHg 14-15 5
 Nadi : ……………x/mnt 11-13 4
Kuat Lemah Regular Irregular
8-10 3
 Suhu Axilla : … . OC Suhu Rectal:.. OC
5-7 2
 Tempratur kulit :  Hangat  Panas Dingin 3-4 1
 Gambaran kulit : Normal Kering
TOTAL TRAUMA SCORE (A+B+C+D+E) =
 Lembab/basah …………….
 Assessment : ……….
 Resusitasi : ………..
 Re-evaluasi : ……….. REAKSI PUPIL
D. Disability Kanan Ukuran ( mm) Kiri Ukuran ( mm)
Alert  Cepat  ………..  ……..
Verbal response  Konstriksi  ………..  …….
Pain response
 Lambat  ………..  …….
Unresponsive
 Dilatasi  ………..  …….
E. Exposure
……………………  Tak bereaksi  ………..  ……
…………………….

3/6
MR
RSUP Dr. Wahidin Sudirohusodo Makassar
Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818

PENGKAJIAN AWAL RAWAT INAP MEDIS


BEDAH - TRAUMA

MR.3a/BEDAH TRAUMA/RI/C/2013

SECONDARY SURVEY :
MR
RSUP Dr. Wahidin Sudirohusodo Makassar
Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818

PENGKAJIAN AWAL RAWAT INAP MEDIS


BEDAH - TRAUMA

MR.3a/BEDAH TRAUMA/RI/C/2013

Nama Pasien : No. Rekam Medis : 4/6

Tgl. Lahir : Ruangan :

ANAMNESIS & PEMERIKSAAN FISIS


. .

Penomoran lokasi luka,fraktur dan trauma lainnya :


1. Laserasi 2. Abrasi 3. Hematoma 4. Kontuiso
5. Dislokasi 6. Fr. Terbuka 7. Luka Tembak 8. Luka Tusuk
9. Luka bakar 10. Luka Dingin 11. Edema 12. Amputasi
MR
RSUP Dr. Wahidin Sudirohusodo Makassar
Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818

PENGKAJIAN AWAL RAWAT INAP MEDIS


BEDAH - TRAUMA

13. Avulse 14. Nyeri 15. Fr. Tertutup 16. Lain-lain ……………….

MR.3a/BEDAH TRAUMA/RI/C/2013
RENCANA KERJA HASIL PEMERIKSAAN PENUNJANG

DIAGNOSA ICD-X TERAPI


5/6
1. ............................................................
2. ............................................................
3. ............................................................
4. ............................................................
5. ............................................................

HASIL PEMBEDAHAN

DIAGNOSE TERAKHIR

DISPOSISI
Hidup : Boleh pulang Jam Keluar: ……………wita Tanggal : ……………………………….
Kontrol polkinik Tidak Ya,………………………. Tanggal: ……………..,………………
Dirawat di ruang : Intensif Lontara II B. Digestif Lontara II B. Urologi
Lontara II B. Onkologi Lontara II B. Ortopedi Lontara III B. Saraf
 Ruang lain: ………………………. Kelas …………………….
Mati:  Death on Arrival
 Setelah resusitasi Jam ………………….. wita Tanggal : …………………………………………………….
 Penyebab kematian : ………………………………………………………………………………………………..….

REKOMENDASI (SARAN ) CATATAN PENTING

Yang Melakukan Pengkajian


Tanggal / Jam : Tanda tangan dokter
Nama Dokter :