Scribd Logo
Upload

Welcome to Scribd!

  • Form Sop

    Uploaded by

    PLN ULP SUKADANA
    6 views3 pages
    This document contains a checklist for initial clinical assessment procedures at a community health center (Puskesmas) in Teluk Melano. The checklist has 15 steps for the assessment process, including identifying the patient, collecting their medical history and current complaints, performing vital sign measurements, conducting a physical exam by the doctor, documenting findings, and making a diagnosis. The checklist is to be used by staff to audit whether the initial assessment is performed correctly according to standard operating procedures.

    Original Description:

    form sop

    Original Title

    FORM SOP (3)

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document contains a checklist for initial clinical assessment procedures at a community health center (Puskesmas) in Teluk Melano. The checklist has 15 steps for the assessment process, including identifying the patient, collecting their medical history and current complaints, performing vital sign measurements, conducting a physical exam by the doctor, documenting findings, and making a diagnosis. The checklist is to be used by staff to audit whether the initial assessment is performed correctly according to standard operating procedures.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    6 views3 pages

    Form Sop

    Uploaded by

    PLN ULP SUKADANA
    This document contains a checklist for initial clinical assessment procedures at a community health center (Puskesmas) in Teluk Melano. The checklist has 15 steps for the assessment process, including identifying the patient, collecting their medical history and current complaints, performing vital sign measurements, conducting a physical exam by the doctor, documenting findings, and making a diagnosis. The checklist is to be used by staff to audit whether the initial assessment is performed correctly according to standard operating procedures.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 3

    No.

    Dokumen : /SOP/PKM-TLM/2023
    No. Revisi : 00
    SOP Tanggal Terbit : 00/00/2023
    Halaman : 1/2

    gudrilogo.blogspot.com

    PUSKESMAS AZWAR ANAS,S.Tr.Kep


    TELUK MELANO NIP. 197705112002121008

    1. Pengertian

    2. Tujuan
    3. Kebijakan

    4. Referensi

    5. Alat dan Bahan

    6. Prosedur/ Langkah-
    langkah

    7. Bagan Alur

    8. Hal-hal yang perlu


    diperhatikan
    9. Unit terkait Penanggung jawab UKP
    10.Dokumen terkait
    11.Rekaman Historis
    No Yang diubah Isi perubahan Tanggal diberlakukan
    No. Dokumen : /SOP/PKM-TLM/2023
    No. Revisi : 00
    SOP Tanggal Terbit : 00/00/2023
    Halaman : 1/2

    gudrilogo.blogspot.com

    PUSKESMAS AZWAR ANAS,S.Tr.Kep


    TELUK MELANO NIP. 197705112002121008

    DAFTAR TILIK

    PENGKAJIAN AWAL KLINIS

    Unit : BP

    Nama Petugas :

    Tanggal Pelaksanaan :

    NO. Langkah Kegiatan YA TIDAK

    1. Apakah petugas unit pelayanan memanggil pasien sesuai nomor


    urut?
    2. Apakah petugas unit pelayanan mempersilahkan pasien untuk
    duduk?
    3. Apakah petugas unit pelayanan menanyakan ulang identitas
    pasien disesuaikan dengan rekam medis pasien?
    4. Apakah petugas unit pelayanan menanyakan keluhan yang
    dirasakan pasien saat ini?
    5. Apakah petugas unit pelayanan menanyakan berapa lama
    keluahan dirasakan?
    6. Apakah petugas unit pelayanan menanyakan mengenai riwayat
    penyakit sebelumnya?
    7. Apakah petugas unit pelayanan menanyakan riwayat makanan
    dan aktivitas yang sebelumnya dilakukan?
    8. Apakah petugas unit pelayanan menanyakan adakah riwayat
    keluarga yang mempunyai riwayat yang sama dengan pasien
    dalam satu rumah?
    9. Apakah petugas unit pelayanan melakukan pemeriksaan vital
    sign pada pasien?
    No. Dokumen : /SOP/PKM-TLM/2023
    No. Revisi : 00
    SOP Tanggal Terbit : 00/00/2023
    Halaman : 1/2

    gudrilogo.blogspot.com

    PUSKESMAS AZWAR ANAS,S.Tr.Kep


    TELUK MELANO NIP. 197705112002121008

    10. Apakah petugas unit pelayanan menanyakan mengenai riwayat


    alergi obat?
    11. Apakah petugas unit pelayanan mencatat hasil anamnesa dan
    pemeriksaan vital sign ke rekam medis sesuai SOAP?
    12. Apakah petugas unit pelayanan menyerahkan rekam medis ke
    dokter pemeriksaan?
    13. Apakah dokter melakukan pemeriksaan fisik?

    14. Apakah dokter mencatat hasil pemeriksaan kedalam rekam


    medis?
    15. Apakah dokter menegakkan diagnosa.?

    Jumlah

    Compliance rate (CR) :…………….%

    Puskesmas Teluk Melano………………………

    Pelaksana/audit

    ………………………………….…

    Nip………………………………

    You might also like