ANAK 1 2 3 4 5 6 7 8 9 10 TOTALUsia0-5 th + +>5 +Jenis KelaminLPStatus GiziLebihBaikKurangLama Perawatan?<6 hari>6 hariKeluhan UtamaSesak (+)=

(-)=Keluhan PenyertaDemam (+)=

(-)=Batuk Berlendir (+)=

(-)=Assesmen KlinisTakikardi (+)=

(-)=Dispneu (+)=

(-)=Retraksi (+)=

(-)=Nafas Cuping Hidung (+)=

(-)=Hipertermi (+)=

(-)=PenunjangLaboratorium darah (+)=

(-)=Foto Thoraks (+)=

(-)=TindakanOksigen + - + (+)=

(-)=ObatAntibiotikAmpisilin+Gentamisin (+)=

(-)=Sefalosporin (+)=

(-)=Antipiretik (+)=

(-)=Nutrisi

OGT (+)= (-)=

Non OGT (+)= (-)=

KomplikasiAsidosis Metabolik (+)=

(-)=Pneumothoraks (+)=

(-)=Pneumomediastinum (+)=

(-)=EdukasiVaksin (+)=

(-)=Kontrol (+)=

(-)=