III. PENGKAJIAN MEDIS

Pemeriksaan Dokter, Pukul :

Subjective :________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Objective :___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Pemeriksaan Penunjang : EKG : _____________________________________________________________________ Radiologi : _____________________________________________________________________ Laboratorium : _____________________________________________________________________

Assessment : Diagnosa Kerja : _______________________________________________________________ Diagnosa Banding : _______________________________________________________________

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Palanning : Penatalaksanaan / Pengobatan / Rencana Tindakan / Konsultasi__________________________Nama / Tanda Tangan Dokter

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