FAKULTAS KEDOKTERAN UNIVERSITAS TANJUNG PURA/RSUD.DR.SOEDARSOPONTIANAK

ASESMEN GERIATRI No.RM

(RAWAT JALAN, MINI-CEX)

Nama : ………………………………………………………………………………………………… Laki-laki/PerempuanUmur : …………………….. ThAgama : Islam/Katolik/Kristen/Hindu/BudhaPendidikan : Tidak sekolah/SD/SMP/SMA/D3/S1/S2/S3Alamat/Hp : …………………………………………………………………………………………………………………………………..Pekerjaan : …………………………………………………………………………………………………………………………………..

A. ANAMNESIS:1. Keluhan Utama : ………………………………………………………………………………………………………,……………..

Riwayat Penyakit sekarang : .………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………….... …………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………....Riwayat penyakit dahulu:…………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………….

2. Kebiasaan : Ya Tidak JumlahMerokok …………………… …………………… ………………………….. perhariMinum alkohol …………………… …………………… ………………………….. perhariMinum kopi …………………… …………………… ………………………….. perhariOlahraga (jenis/intensitas)……………………………………………………………………………………………….............……………………………………………………………………………………………………………………………………….............. Dengan resep dokter Dosis dan lama pemakaian………………………………………………………. ……………………………………………………………………….............………………………………………………………. ……………………………………………………………………….............………………………………………………………. ………………………………………………………………………............. Tanpa resep dokter Dosis dan lama pemakaian………………………………………………………. ……………………………………………………………………….............………………………………………………………. ……………………………………………………………………….............

B. PEMERIKSAAN FISIK:1. Kesan Umum………………………………………………………………………………….......2. Tanda vital

Kesadaran : Kompos mentis/apatis/somnolen/sopour/coma/………………………. Baring Duduk Berdiri

Tekanan darah (TD)* ………………….. …………………….. ………………………….. Nadi/menit ………………….. …………………….. ………………………….. Laju respirasi/menit ………………….. …………………….. …………………………..

(*ukur TD setelah 2 menit pada posisi tersebut) Suhu ……………………derajat Celcius

3. Tanda-tanda pentinga. Sindrom Geriatri

.........................................................................................................................................b. Gejala –gejala penting

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IDENTITAS PASIEN

FAKULTAS KEDOKTERAN UNIVERSITAS TANJUNG PURA/RSUD.DR.SOEDARSOPONTIANAK

ASESMEN GERIATRI No.RM

(RAWAT JALAN, MINI-CEX)

c. Kelainan fisik penting..............................................................................................................................................................................................................................................................................................................................................................................................................................

d. Kelainan psikologik....................................................................................................................................................................................................................................................................................

C. DIAGNOSIS

C1.Geriatri :……………………………………………………….......................................................................

C2.Patologis:.………………………………………………..... ………………….................................................

..…………………………………………………... ...................................................................

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C3.Psikologis:....................................................... ...................................................................

D.GANGGUAN

1………………………………………………………............ 3.…………………………………………………………………

2..................................................................... 4.....................................................................

E. KETIDAK MAMPUAN 1...................................................................... 3.....................................................................

. 2...................................................................... 4.....................................................................

F.HAMBATAN

1……………………………………………………… 3.……………………………………………………………………………

2..…………………………………………………… 4.……………………………………………………………………………

G.TATALAKSANA

1. Non Medikamentosa ………………………………..……………………………………………………………… ……………………………………………………………………..……………………………………………………………… ……………………………………………………………………..………………………………………………………………

2. Medikamentosa …………………………………………………………………..…………………………………… ……………………………………………………………………..……………………………………………………………… …………………………………………………………………………………………………………………………………….

F. REKOMENDASI

…………………….………………………………………………………………………....................................... ………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………..

PONTIANAK, …………………………

Pembuat Asesmen

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