9.

Brief Head to Toe examination :

Head & Upper
Chest Abdomen Back & Bottom Anus Lower Extremities
Neck Extremities
Normal normal normal normal normal - normal

10. Additional Information (if any):

Treatment Given So Far: Patients Response to the Treatment:

(tick the appropriate box and add remark)
Improved

- O2 5 lpm 30 menit Unchanged

Deteriorated

Plan of Action (What are you going to do now?) What specific information do you want from the CD?
Tick the appropriate box & add remark if any Tick the appropriate box & add remark if any

To observe the patient temporarily on site FA Post / Approval for medication and or treatment plan
clinic.
To give the patient further medication / treatment as Further additional prescriptions and recommendation by CD.
advised by CD
Planning to refer and OR evacuate the patient to the Approval for referral and OR evacuation plan
nearest hospital to get further comprehensive
investigation and or treatment
Kesimpulan : Berdasarkan pemeriksaan fisik yang dilakukan, di temukan luka gores kemerahan pada lengan kanan dan
tidak ditemukan cidera berat pada pasien. Tidak ada tanda-tanda perdarahan aktif pada luka.
Setelah di observasi selama 2 jam dan perawatan luka, pasien mengalami perbaikan keadaan umum. Pasien dapat
berjalan dengan normal tanpa adanya rasa pusing.

Pasien dapat bekerja tanpa ada keluhan apapun.

Site Medical Staff Name: dr. Dedy PS Signature:

Intl. RMC Physicians Advice (to be completed by RMC Assistance Centre and emailed/faxed back
to site)

Assistance Centre Physician Name: __________________Signature:

_____________________