RUMAH SAKIT MELATI Nama : …………...……………...

L P
Jln. Merdeka No. 92 Tangerang
Telp : (021) 5523945 (hunting), 55776739 Tgl. Lahir : …../.…./….…............ Th Bln
Fax. (021) 55769914, 5530670
Email : Info@rsmelati.co.id No. RM :
ASESMEN AWAL PENYAKIT DALAM RAWAT JALAN
PemeriksaanTanggal : ............/........../............... Jam : ......................... Wib
1. ASESMEN PERAWAT NamaPerawat : Tandatangan :

A. Data Subyektif : Ananmnese : ................................................................................................................................................

B. Riawayat Penyakit : .................................................................................................................................. .............................
.................................................................................................................................................................................................
C. Data Obyektif :
Keadaan Umum: Baik Sedang Buruk, Keadaan Gizi : Baik Cukup Kurang
Tensi : ………/……,mm.Hg Nadi :……………………….x/mnt Suhu : ……………………………C°
Nafas :…………….x/mnt Skala nyeri :……………... BB : .......................................…...kg
TB : ....................Cm Kesadaran / gcs : .............................................................................................................
2. ASESMEN DOKTER
A. Data Subyektif :
Keluhan utama : ..................................................................................................................... .........................................................
Riwayat penyakit sekarang :…........................................................................................................................................................
.........................................................................................................................................................................................................
Riwayat penyakit dahulu : .................................................................................................................... ..........................................
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Riwayat penyakit keluarga : ...........................................................................................................................................................
Riwayat Alergi : .............................................................................................................................................................................
Riwayat Pribadi :  merokok  minum alcohol  olah raga, frekuensi :…………………………………………….....
B. Data Objektif :
Kondisi umum : ..............................................................................................................................................................................
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Kepala leher :..................................................................................................................................................................................
Thorax : ...........................................................................................................................................................................................
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Abdomen : ......................................................................................................................................................................... ..............
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Ekstermitas : ............................................................................................................... ....................................................................
Pemeriksaan Penunjang : ............................................................................................................................. ..................................
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…………………………………………………………………………………………………………………………………….
C. Diagnosis :............................................................................................................................ .....................................................
Diagnosis Banding : .................................................................................................................................................................
D. Rencana / Terapi: ........................................................................................................................... .........................................
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Tangerang :…………/........./………..
Tandatangan

(......................................................)
NamadanTangan
Berilah tanda ceklis (√) pada kolom yang sesuai RJ-RM 07a/RSM/2016
Berilah tanda silang (X) pada kolom yang tidak sesuai
Isilah ............ diatas dengan benar
Bubuhkan tandatangan pada kolom yang disediakan
Berilah tanda ceklis (√) pada kolom yang sesuai RJ-RM 07a/RSM/2016
Berilah tanda silang (X) pada kolom yang tidak sesuai
Isilah ............ diatas dengan benar
Bubuhkan tandatangan pada kolom yang disediakan