DINAS KESEHATAN KABUPATEN TASIKMALAYA

UPT PUSKESMAS SUKARAME No. Rekam Medis : .........................................................

Jl. Raya Sukarame No. 117 Telp. (0265) 546657
Kabupaten Tasikmalaya Nama : ................................................ L / P

Tgl. Lahir / umur : .........................................................

PENGKAJIAN AWAL PASIEN RAWAT JALAN
(Diisi pada saat pasien pertama kali datang ke puskesmas) Ruangan / Unit : .........................................................

Jenis Pelayanan : Tanggal : Jam :

1. SUBJECTIVE
ANAMNESA
Keluhan Utama : ........................................................................................................................
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Keluhan Tambahan : ........................................................................................................................

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Riwayat Penyakit Sekarang : ........................................................................................................................

RAWAT JALAN ........................................................................................................................

Riwayat Penyakit Dahulu

TANPA COVER : ........................................................................................................................
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Riwayat Penyakit Keluarga REVISI LAGI : ........................................................................................................................

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Riwayat Alergi
06 09 2018 : ........................................................................................................................
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Obat yang sedang dikonsumsi : ........................................................................................................................

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2. OBJECTIVE
A. PEMERIKSAAN TANDA-TANDA VITAL :
1. Keadaan Umum : c Baik c Sedang c Lemah
2. Kesadaran : CM / Somnolen / Sopor / Koma

TD : .......... / .......... mmHg, Frek. Nadi : .......... x/menit, Frek. Nafas : .......... x/menit, Suhu : .......... °C
BB : .......... Kg, TB : .......... Cm

B. PEMERIKSAAN FISIK

Kepala / Leher : ....................................................................................................................................................

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Thorax : ....................................................................................................................................................
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Abdomen : ....................................................................................................................................................
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Ekstremitas l ....................................................................................................................................................
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Lainnya : ....................................................................................................................................................
 C. STATUS PSIKO SOSIOKULTURAL DAN SPIRITUAL
Status Mental : Orientasi Baik / Disorientasi / Gelisah / Tidak Respon
Respon Emosi : Tenang / Sedih / Takut / Gelisah / Menangis / Tegang / Marah
Hubungan Pasien Dengan Keluarga : Baik / Tidak Baik
Bahasa : Indonesia / Sunda / Lainnya ................................................................
D. PEMERIKSAAN PENUNJANG : (Lab. / EKG / USG / Rontgent / ................................. Tgl :
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3. ASSESMENT
Diagnosis : ........................................................................
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ICD 10 : ........................................................................
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4. PLANNING
RAWAT JALAN
Rencana Pelayanan Medis :
a. Rencana Tindakan / Pengobatan :
TANPA COVER
REVISI LAGI
........................................................................................
........................................................................................
06 09 2018
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b. Rencana Edukasi :
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c. Rencana Diagnostik :
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d. Rencana Monitoring :
Kontrol Kembali Tanggal : ..............................................
Lainnya : ........................................................................
e. Rencana Rujukan :
Rujuk ke RS : ................................................................
Poli : ..............................................................................
f. Rencana Pelayanan Lainnya :
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Dokter Penanggung Jawab Pelayanan,
( ........................................................................ )
/ / )
Diagnosis Keperawatan / Kebidanan :
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Rencana Asuhan Pelayanan Keperawatan :
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Perawat,
( ........................................................................ )
 No. Rekam Medis : .........................................................
DINAS KESEHATAN KABUPATEN TASIKMALAYA
UPT PUSKESMAS SUKARAME Nama : ................................................ L / P
Jl. Raya Sukarame No. 117 Telp. (0265) 546657 Tgl. Lahir / umur : .........................................................
Kabupaten Tasikmalaya
Ruangan / Unit : .........................................................

CATATAN PERKEMBANGAN PASIEN

Ditulis dengan SOAP
DIAGNOSA & PERENCANAAN Nama &
ANAMNESA & PEMERIKSAAN
Tanggal / Jam KODE ICD LAYANAN Paraf
(Subjective - Objective)
(Assesment) (Planning) Petugas

RAWAT JALAN
TANPA COVER
REVISI LAGI
06 09 2018

3
 DINAS KESEHATAN KABUPATEN TASIKMALAYA
UPT PUSKESMAS SUKARAME No. Rekam Medis : .........................................................
Jl. Raya Sukarame No. 117 Telp. (0265) 546657
Kabupaten Tasikmalaya Nama : ................................................ L / P

Tgl. Lahir / umur : .........................................................

CATATAN PERKEMBANGAN
PASIEN TERINTEGRASI Ruangan / Unit : .........................................................

DIAGNOSA & PERENCANAAN Nama &

ANAMNESA & PEMERIKSAAN
Tanggal / Jam KODE ICD LAYANAN Paraf
(Subjective - Objective)
(Assesment) (Planning) Petugas

RAWAT JALAN
TANPA COVER
REVISI LAGI
06 09 2018