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RUMAH SAKIT MISI LEBAK (penempelan stiker identitas)

Jl. Multatuli No. 41 Rangkasbitung 42311 Lebak – Banten
Telp. 0252-201014 Fax. 0252-203390
e-mail : rsmisilebak@gmail.com
Nama Pasien : …………………………………..
Jenis Kelamin : Laki-laki / Perempuan *
Tgl Lahir/Umur : ……………………………………
Alamat : ……………………………………

ASESMEN MEDIS
RAWAT INAP GENERAL
Tanggal : Jam :
STATUS GENERAL
A. ANAMNESA
1. Keluhan Utama
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2. Riwayat penyakit dahulu
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3. Riwayat penyakit sekarang
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4. Riwayat penyakit keluarga
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PEMERIKSAAN FISIK
1. Vital Sign
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2. Cranium
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3. Leher
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4. Thorax
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5. Abdomen
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6. Genitalia
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7. Extremitas
a. Ex. Atas
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b. Ex. Bawah
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STATUS LOKALIS
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DIAGNOSIS PENUNJANG
1. Laboratorium
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2. Radiologi
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3. ECG
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4. Lain - lain
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DIAGNOSIS

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TERAPI

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Rangkasbitung, ……………………………………………………………
Dokter Penanggung Jawab Perawatan
(DPJP)

( ………………………………………………………………… )
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