MR. 3a/BEDAH NON TRAUMA/R.

I/C/2013

RSUP Dr. Wahidin Sudirohusodo Makassar

Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818

PENGKAJIAN AWAL RAWAT INAP MEDIS

BEDAH - NON TRAUMA

Ruangan : Tanggal : Jam :

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

Nama Lengkap : .....................................................................................................................................................................................
Jenis Kelamin : .....................................................................................................................................................................................
Tanggal Lahir : .....................................................................................................................................................................................
Alamat : .....................................................................................................................................................................................
Rujukan : Ya, dari, RS ....................... Puskesmas ........................ Praktek ............................ 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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 RSUP Dr. Wahidin Sudirohusodo Makassar
Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818

PENGKAJIAN AWAL RAWAT INAP MEDIS

BEDAH - NON TRAUMA

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 MR. 3a/BEDAH NON TRAUMA/R.I/C/2013

RSUP Dr. Wahidin Sudirohusodo Makassar

Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818

PENGKAJIAN AWAL RAWAT INAP MEDIS

BEDAH - NON TRAUMA

Nama Pasien : No. Rekam Medis : Tgl. Lahir : Ruangan :

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
Nyeri : Tidak
Ya: Lokasi: …………….……. Intensitas …… Skor : …… (Metode VAS/BPS/NIPS/FLACC)

Jenis : Akut
Kronis

TANDA-TANDA VITAL
Keadaan Umum : Baik Sedang Lemah Jelek, Gizi : Baik Kurang Buruk
GCS : E….... M….... V….…. Tindakan Resusitasi: Ya Tidak
BB : ………… Kg TB:……… cm
Tek. Darah: …………. mmHg, Nadi: …………. x/mnt
Respirasi: …….. x/mnt, Suhu Axila/Rektal: ………… OC/……………. OC

PEMERIKSAAN FISIS
Mata : Anemis : Tidak Ada, Ikterus : Tidak Ada, Pupil : anisokor Isokor, diameter ........../.......... mm,
Udem Palpebrae : Tidak Ada
THT : Tonsil : …………………, Faring : ………………………, Lidah : ………………………., Bibir :…………......……......................
Leher : JVP : ………………….., Pembesaran Kelenjar Limfe: Tidak Ada, ........................................... Kaku kuduk : Tidak Ada
Thoraks : Simetris Asimetris: ...................................................................................................................................
Cor : S1/S2 ……………………………. Reguler Ireguler, Murmur .......................................................................
Lain-lain : ..............................................................................................................................................................................
Pulmo : Suara Nafas : ......................................, Ronchi : Tidak Ada ....................................................................
Wheezing : Tidak Ada, ............................................................................................................................
Abdomen : Distended : Tidak Ada, Meteorismus : Tidak Ada

Peristaltik : Normal Meningkat menurun Tidak ada, Asites: Tidak Ada

Nyeri Tekan : Tidak Ada, Lokasi : ............................................................................................................

Hepar : .........................................................., Lien : ..........................................................................................
Extremitas : Hangat Dingin Udem : Tidak Ada, ..................................................................
Lain-Lain: ..............................................................................................................................................................

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

PENGKAJIAN AWAL RAWAT INAP MEDIS

BEDAH - NON TRAUMA

STATUS LOKALIS

HASIL PEMERIKSAAN PENUNJANG DIAGNOSA

1. ....................................................................................................
2. ....................................................................................................
3. ....................................................................................................
4. ....................................................................................................
5. ....................................................................................................
TERAPI

RENCANA KERJA

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 MR. 3a/BEDAH NON TRAUMA/R.I/C/2013

RSUP Dr. Wahidin Sudirohusodo Makassar

Jl. Perintis Kemerdekaan Km 11 Telp. (0411) 584675-581818

PENGKAJIAN AWAL RAWAT INAP MEDIS

BEDAH - NON TRAUMA

Nama Pasien : No. Rekam Medis : Tgl. Lahir : Ruangan :

HASIL PEMBEDAHAN

DIAGNOSA AKHIR

DISPOSISI
Hidup : Boleh pulang Jam Keluar: ……………wita Tanggal : ……………………………….
Kontrol polkinik : Tidak Ya,………………………. Tanggal: ……………..,………………
Dirawat di ruang : Intensif/ ICU Lontara II B. Digestif Lontara II B. Urologi

Lontara II B. Onkologi Lontara II B. Ortopedi Lontara III B. Saraf

Lontara II B. Anak

 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 :

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