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  • Asesmen Medis Rawat Inap Hal 2

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    Siska indah sari
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    This document contains a patient's medical record information including their name, medical record number, date of birth, address, gender, medical history, physical examination findings, working diagnoses, differential diagnoses, treatment plan, monitoring plan, and education provided to the patient and family. The treatment plan involves both operative and non-operative interventions, planned consultations, anticipated length of stay, discharge plan, and overall treatment goals. The attending physician signs off on the care plan.

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    assesmen medis

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    Asesmen medis rawat inap hal 2

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    This document contains a patient's medical record information including their name, medical record number, date of birth, address, gender, medical history, physical examination findings, working diagnoses, differential diagnoses, treatment plan, monitoring plan, and education provided to the patient and family. The treatment plan involves both operative and non-operative interventions, planned consultations, anticipated length of stay, discharge plan, and overall treatment goals. The attending physician signs off on the care plan.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    6 views1 page

    Asesmen Medis Rawat Inap Hal 2

    Uploaded by

    Siska indah sari
    This document contains a patient's medical record information including their name, medical record number, date of birth, address, gender, medical history, physical examination findings, working diagnoses, differential diagnoses, treatment plan, monitoring plan, and education provided to the patient and family. The treatment plan involves both operative and non-operative interventions, planned consultations, anticipated length of stay, discharge plan, and overall treatment goals. The attending physician signs off on the care plan.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 1

    Label Identitas Pasien

    Nama :
    No. RM :
    Tgl. Lahir :
    Alamat :
    Jenis Kelamin :

    □ Hematuria □ Piuria □ Oliguria □ Inkontinesia □ Perdarahan □ Tumor □ Perdarahan


    Genitalia
    per vagina □Lainnya...........................................................
    Riwayat Reproduksi
    □ Haid Pertama ........ Tahun □ Siklus Haid..... Hari □ Riwayat G....P...A.... □ Lainnya
    Wanita
    Muskuloskeletel □ Nyeri sendi.................. □ Paratese............... □ Edema........... □ Tremor............ □ Trauma............ □
    Lainnya..............
    Tambahan Pemeriksaan Fisik/ Neurologis
    Pemeriksaan Penunjang
    Daftar Masalah :
    1. ..................................................................................
    2. ..................................................................................
    3. ..................................................................................
    4. ..................................................................................
    5. ..................................................................................
    Diagnosa Kerja :

    Diagnosa Banding :

    Program dan Terapi :

    Monitoring :

    Edukasi awal disampaikan tentang Diagnosis, Rencana dan Tujuan Terapi Kepada:
    □ Pasien
    □ Keluarga Pasien, nama........................................................ Hubungan dengan pasien.......................................
    Tidak diberikan edukasi, karena...............................................................................................................................
    Rencana Tindakan Medis
    □ Operatif : .................................................................................................................................
    .................................................................................................................................
    .................................................................................................................................
    □ Non Operatif : .............................................................................................................................
    .............................................................................................................................
    .............................................................................................................................
    Rencana Konsultasi :
    Rencana Lama Perawatan :
    Rencana Pemulangan (termasuk pada apsien dengan kondisi kritis seperti pasien stroke, memerlukan hme care,
    perlu alat bantuan tertentu, paliatif,
    dll) :........................................................................................................................................
    .........................................................................................................................................
    Tujuan Akhir Pengobatan dan
    Perawatan :..........................................................................................................................
    .................................................................................................................
    ..........
    Nama terang dan tanda tangan DPJP

    ............................................................

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