KOLEGIUM PENYAKIT DALAM (KIPD)

CATATAN MEDIK PASIEN

No. Reg. RS :

Nama Lengkap : ...........................................................................................................................................

Tanggal Lahir : ...................................................... Umur : ................Tahun Jenis Kelamin : L/ P

Alamat : Nomor telepon : ........................

Pekerjaan : ............................................................... Status : Belum menikah/ Menikah/ Janda/ Duda

Pendidikan : ........................................ Etnis/ Suku : ........................... Agama :..........................

Dokter : ..........................................................
Tanggal : ................................. Jam : ..........

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ANAMNESIS
Autoanamnesis Alloanamnesis
RIWAYAT PENYAKIT SEKARANG
Keluhan utama : ________________________________________________________________
Riwayat perjalanan penyakit :
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RIWAYAT PENYAKIT DAHULU

Tanggal Penyakit Tempat Perawatan Pengobatan dan Operasi

RIWAYAT KELUARGA  Laki-laki Perempuan

X Meninggal (sebutkan sebab meninggal dan umur saat meninggal)

Kakek – Nenek

Ayah - Ibu

Pasien

Anak

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RIWAYAT PRIBADI

Riwayat Alergi Riwayat imunisasi

Tahun Bahan/ Obat Gejala Tahun Jenis imunisasi

Hobi : ____________________________________________________________________________

Olah raga : _________________________________________________________________________

Kebiasaan makan : __________________________________________________________________

Merokok : __________________________________________________________________________

Minum alkohol : ________________________________________________________________________

Hubungan seks : _______________________________________________________________________

Penggunaan obat-obatan : _____________________________________________________________

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ANAMNESIS UMUM (Review of System)
Berilah tanda bila abnormal dan berikan deskripsi

 Umum
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 Kulit
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 Kepala dan leher

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 Mata
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 Telinga
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 Hidung
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 Mulut dan Tenggorokan

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 Pernafasan
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 Payudara
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 Jantung
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 Vaskuler
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 Abdomen
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 Ginekologi
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 Alat kelamin laki-laki

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 Ginjal dan Saluran Kemih

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 Hematologi
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 Endokrin/ Metabolik
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 Muskoskeletal
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 Sistem syaraf
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 Emosi/ Status Psikologis

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DESKRIPSI UMUM
Kesan sakit :  Ringan  Sedang  Berat
Gizi :

Berat Badan : ........................... kg ; Tinggi badan : ...................cm ; IMT : .......................... kg/ m2

TANDA VITAL

Kesadaran :

Nadi Frekuensi : / menit Deskripsi :

Tekanan darah Berbaring : Duduk :

(mmHg) Lengan Kanan : Lengan Kanan :
Lengan Kiri : Lengan Kiri :

Temperatur Aksila : Rektal :

( ° Celcius )

Pernafasan Frekuensi : / menit Deskripsi :

Kulit _______________________________________________________________
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Kepala dan leher _______________________________________________________________
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Telinga ________________________________________________________________
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Hidung ________________________________________________________________
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Rongga mulut ________________________________________
Dan Tenggorokan ________________________________________
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Mata _______________
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Toraks Kiri Kanan ________________________________________________________________
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Jantung ________________________________________________________________
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Paru-paru ________________________________________________________________
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Abdomen _______________________________________
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Ekstremitas _______________________________________________________________
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Alat kelamin ________________________________________________________________
Laki-laki : ________________________________________________________________
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Perempuan ________________________________________________________________
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Rektum ________________________________________________________________
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Neurologi ________________________________________________________________
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Laboratorium ________________________________________________________________
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 RESUME DATA DASAR
(Diisi dengan Temuan Positif)

Oleh dokter : .................................................................

Nama Penderita : ............................................................................................... No. RM :

1. KELUHAN UTAMA :

2. ANAMNESIS : (Riwayat Penyakit Sekarang, Riwayat Penyakit Dahulu, Riwayat

Pengobatan, Riwayat Penyakit Keluarga, dll.)

3. PEMERIKSAAN FISIK :

4. PEMERIKSAAN TAMBAHAN
A. Laboratorium :

B. Radiologi :

C. Lain – lain :

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MASALAH DAN PENGKAJIAN

1. Masalah :

Pengkajian :

2. Masalah :

Pengkajian :

3. Masalah :

Pengkajian :

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4. Masalah :

Pengkajian :

5. Masalah :

Pengkajian :

6. Masalah :

Pengkajian :

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 RENCANA AWAL

Nama Penderita:
Th.
No. RM:
Rencana yang akan dilakukan untuk masing-masing masalah
(meliputi rencana untuk diagnosis, penatalaksanaan dan edukasi)

No. Rencana diagnosis Rencana Terapi Rencana Edukasi Rencana

Masalah
Monitoring

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KESIMPULAN :

PROGNOSIS :

Ad vitam :
Ad functionam :
Ad sanationam :

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 LEMBAR EVALUASI

NAMA : …………………………………………

TEMPAT ROTASI : …………………………………………

MATERI : PENGISIAN REKAM MEDIS PASIEN

MINGGU KE : ................................................................

HASIL EVALUASI

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SARAN :

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Pembimbing/Tutorial Klinik

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