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    RM 3 Ugd Assesment Medis Ugd

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    Hajrah Said
    1. This document appears to be a medical record form for patients presenting to the emergency department. 2. It collects information about the patient's identity, medical history, presenting complaint, physical exam findings, diagnostic tests, assessment, and treatment plan. 3. The form is multi-page and collects both subjective and objective information to guide clinicians in diagnosing and managing the patient's condition.

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    RM 3 Ugd Assesment Medis Ugd

    Uploaded by

    Hajrah Said
    41 views3 pages
    1. This document appears to be a medical record form for patients presenting to the emergency department. 2. It collects information about the patient's identity, medical history, presenting complaint, physical exam findings, diagnostic tests, assessment, and treatment plan. 3. The form is multi-page and collects both subjective and objective information to guide clinicians in diagnosing and managing the patient's condition.

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    Rm 3 Ugd Assesment Medis Ugd

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    1. This document appears to be a medical record form for patients presenting to the emergency department. 2. It collects information about the patient's identity, medical history, presenting complaint, physical exam findings, diagnostic tests, assessment, and treatment plan. 3. The form is multi-page and collects both subjective and objective information to guide clinicians in diagnosing and managing the patient's condition.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    41 views3 pages

    RM 3 Ugd Assesment Medis Ugd

    Uploaded by

    Hajrah Said
    1. This document appears to be a medical record form for patients presenting to the emergency department. 2. It collects information about the patient's identity, medical history, presenting complaint, physical exam findings, diagnostic tests, assessment, and treatment plan. 3. The form is multi-page and collects both subjective and objective information to guide clinicians in diagnosing and managing the patient's condition.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    RM : 3/UGD

    N NAMA PASIEN : HARI : SENIN SELASA RABU KAMIS JUMAT SABTU MINGGU NO REKAM MEDIS :
    TGL : JAM : ,WITA

    UMUR : THN BULAN STATUS PERKAWINAN : AGAMA : PEKERJAAN :


    JENIS KELAMIN : L / P K / BK / J /D /DU
    CARA MASUK RS : 1. DATANG SENDIRI 2. KELUARGA 3. POLISI 4. LAINNYA ......................
    ALAMAT & NO. TELP PASIEN : ALAMAT & NO TELP LAIN YANG DAPAT DIHUBUNGI :

    TEMPAT KECELAKAAN : TGL & JAM KECELAKAAAN : JENIS KECELAKAAN / KENDARAAN


    KLL / KDRT / KK / .......................
    KETERANGAN DIPOEROLEH DARI : NAMA PETUGAS MR : TANDA TANGAN :

    ASSESMENT MEDIS UGD DIISI OLEH DOKTER


    SUBYEKTIF (Keluhan utama, penyerta, riwayatpenyakit dan pengobatan) Keadaan umum :
    Keluhan u tama…………………………………………………………………………………………….
    Tidak tampak sakit/sakit ringan/sakit sedang/
    sakit berat
    ………………………………………………………………………………………………………………………..
    Kesadaran :
    ……………………………………………………………………………………………………………………….
    sadar/apatis/delirium/somnolen/sopor/koma
    ……………………………………………………………………………………………………………………….. GCS : E….. M….. V…….

    ……………………………………………………………………………………………………………………….. TANDA VITAL


    TD : …………..mm/Hg P : ………..x/I
    ………………………………………………………………………………………………………………………..

    Riwayat Penyakit sekarang....................................................................................


    N : …………x/I S : ………...0C
    ..............................................................................................................................

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

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

    Riwayat pengobatan

    ,………………………………………………………….................................................................

    ………………………………………………………………………………………………………………………..

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

    .............................................................................................................................
    RM : 3/UGD/Lanjutan

    OBYEKTIF (Kepala/leher, Thoraks/jantung, Abdomen, Vertebra, anggota gerak, Neurologis ) STATUS LOKALISdan PERLUKAAN

    Kepala/leher…………………………………………………………………………………………………….

    ………………………………………………………………………………………………………………………..

    Thoraks/jantung………………………………………………………………………………………………..

    ………………………………………………………………………………………………………………………..

    ………………………………………………………………………………………………………………………..

    Abdomen………………………………………………………………………………………………………….

    ………………………………………………………………………………………………………………………..

    Vertebra…………………………………………………………………………………………………………..

    ……………………………………………………………………………………………………………………….

    Anggota gerak…………………………………………………………………………………………………..

    ……………………………………………………………………………………………………………………….. KODE GAMBAR


    A : abrasi / ekskoreasi L : Laserasi
    Status Lokasis ………………………………………………………………………………………………….. C : Combustio U : Ulkus
    D : Deformitas N : Nyeri
    ………………….……………………………………………………………………………………………………. H :Hematom O : Lain-lain, ditulis…

    Neurologis………………………………………………………………………………………………........

    PemeriksaanPenunjang

    1. Laboratorium :…………………………………………………… 3. Ultrasonografi…………………………………………………………..


    ………………………………………………………………………… …………………………………………………………………………………
    ………………………………………………………………………… …………………………………………………………………………………
    2. X ray : ………………………………………………………........ 4. Elektrokardiografi :…………………………………………………….
    ………………………………………………………………………… …………………………………………………………………………………..
    ………………………………………………………………………… ……………………………………………………………………………………

    ASSESMEN ( Diagnosis kerja, diagnosis banding)

    1. ……………………………………………………………………………………………………………
    2. ……………………………………………………………………………………………………………
    3. …………………………………………………………………………………………………………..
    4. …………………………………………………………………………………………………………..
    RM : 3 /UGD/Lanjutan

    PLANNING ( Penatalaksanaan, pengobatan (injeksi dan oral), rencana tindakan dan konsultasi )

    1. ….…………………………………………………………………..…………………………………..
    2. ………………………………………………………………………..…………………………………
    3. …………………………………………………………………………..………………………………
    4. ………………………………………………………………………….………………………………
    5. ……………….………………………………………………………….………………………………
    6. ……………………………………………………………………….…………………………………
    7. …………………………………………………………………………………………………………..
    8. …………………………………………………………………………………………………………..
    9. ……………………………………………………………….…………………………………………..
    10. ……………………………………………………………………………………………………………
    11. ……………………………………………………………………………………………………………
    12. ……………………………………………………………………………………………………………

    Konsultasi 1. Bagian ......................................... diminta jam .............................. datang jam ...........................


    2. Bagian .......................................... diminta jam .............................. datang jam ..........................
    3. Bagian .......................................... diminta jam .............................. datang jam ...........................

    Disposisi :  Observasi  Dipulangkan  PAPS  Dirujuk ke …………………….…  Rawat inap …………………………………


    Keadaan Saat Pulang : Sembuh Membaik  Meninggal, setelah dirawat selama……………………………………………

    Nama Dokter : TandaTangan Dokter :

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