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STATUS PASIEN

I. IDENTITAS

1. Nama : .....................................................................................................................

2. Usia : .....................................................................................................................3. Jenis Kelamin : Laki-laki/Perempuan

4. Suku/Bangsa : .....................................................................................................................

5. Agama : slam/Ka!"lik/Kris!en/Bu##$a/%in#u/........................................................&. Alama! : .....................................................................................................................

'. N". () : .....................................................................................................................

*. +anggal )(S : .....................................................................................................................

II. ANAMNESIS

Anamnesis #ilakukan se,ara: au!"anamnesis/al"anamnesis #engan ....................................

pa#a !anggal ........................................................ pukul....................................................................

1. Kelu$an U!ama : .....................................................................................................................

2. (iaa! Penaki! Sekarang.....................................................................................................................................................

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3. (iaa! Penaki! a$ulu

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4. (iaa! Penaki! Keluarga #an S"sial 0k"n"mi

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5. (iaa! Kela$iran

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&. (iaa! Pemerian )akanan

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'. (iaa! munisasi

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*. (iaa! +umu$ Kemang.....................................................................................................................................................

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III. PEMERIKSAAN FISIK

Pemeriksaan isik #ilakukan pa#a !anggal...................................pukul...............................

1. Kea#aan Umum : ....................................................................................................................

2. Kesa#aran : ....................................................................................................................

3. +an#a i!al :

a. +ekanan #ara$ : ............................. mm%g. Na#i : ............................ /meni! .........................................................................

,. La6u Naas : ............................ /meni! .........................................................................#. Su$u : ............................ "7

4. An!r"p"me!ri :

a. Bera! a#an : ..................................................................................................................... +inggi a#an : ....................................................................................................................

5. S!a!us 8i9i : ....................................................................................................................

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....................................................................................................................&. S!a!us 8eneralis :

a. Kuli! : ....................................................................................................................

. Kepala : ....................................................................................................................,. )a!a : ....................................................................................................................

#. +%+ : ....................................................................................................................

e. Le$er : ..................................................................................................................... +$"raks-Kar#i"askular

nspeksi : ....................................................................................................................

Palpasi : ....................................................................................................................

Perkusi : ....................................................................................................................

Auskul!asi : ....................................................................................................................

g. A#"men

nspeksi : ....................................................................................................................

Auskul!asi : ....................................................................................................................

Palpasi : ....................................................................................................................

Perkusi : ....................................................................................................................

$. Ur"-geni!al : ....................................................................................................................

i. Anus/rek!um : ....................................................................................................................

6. 0ks!remi!as : ....................................................................................................................

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'. S!a!us L"kalis : ....................................................................................................................

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IV. PEMERIKSAAN PENUNJANG

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V. DAFTAR MASALAH

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VI. DIAGNOSIS

iagn"sis ker6a: .............................................................................................................................

iagn"sis an#ing : .......................................................................................................................

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VII. TERAPI

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VIII. PROGNOSIS

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