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7/23/2019 Format Status RM IGD-New.1
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IDENTITAS TAMBAHAN PASIENNama Orang tua(ibu Kandung) : ..No. KTP/SIM/PASPOR(WNA)* :
Agama* : Isam / !indu / "ud#a / Krist$n : / %ain&ain :..Aamat Ruma# :
.. ...T$$'on/!P :
.
$sa / K$ura#an / K$amatan :
.
Kota / Kabu'at$n :
Pro'insi / N$gara (WNA) :
..
P$$r+aan :
.
Tangga Masu : #ari . / buan / ta#un . ,am Masu : -ib
,$nis Kun+ungan* : atang S$ndiri / Ru+uan / Kiriman dari: RS / Pus$smas / ot$r / %ain&ain :.
P$ngantar : Nama ...................................................... Status* : K$uarga / Poisi / %ain&ain :. Aamat T$$'on/!P :.
Anamnesis
K$u#an :
Ri-aat '$nait............................................................................................................................... :
Ri-aat a$rgi:
Pemeriksaan FisikK$sadaran : Tanda 0ita(0S) : T: mm!g1 N: 2/mnt1 P: 2/mnt1 S:341 Sat.O5: 674S (89&) :K$'aa :
..
Mata :
.
.
.
.
T$inga :
..
!idung :
..
"ibir :
Muut :
7igi :
.
%$#$r:
..
ada : .................................
,antung..................................:
.................................
Paru.......................................:
.....................................
Abdom$n...............................:
...............................
!$'ar.....................................:
%i$n: .....................................
7in+a.....................................:
K$mauan...............................:
;str$mitas Atas : .................
.
;str$mitas "a-a# :..
..
Pemeriksaan Penunjang / Code ICD-9 CM :%aboratorium:
;47 :..............................................................
Radioogi :..............................................................
K#usus/ :..............................................................
Diagnosis !erja / Code ICD "# :
Diagnosis Banding / Code ICD "# :
Pengo$a%an
INSTA&ASI 'A(ATDA)*)AT +I'D,
No.R$am M$dis : B / &
Nama Pasi$n :
S%a%usPem$a.aran
*mum :
BPS :In0ea1%0 :P!S :
)uma0 Saki% Is1am Si%i
)a0ma0Dengan Ridho ALLAH SWT, Kesehatan Anda Adalah
Tujuan Kami
ATS 2"
ATS 23
ATS 24
7/23/2019 Format Status RM IGD-New.1
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Tindakan / ICD-9 CM :
7/23/2019 Format Status RM IGD-New.1
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Ska1a N.eri WONG BAKER FAE RAT!NG SALE AND N"#ER! SALE * ("$riTanda Siang)
S%a%us &oka1is &uka
8. R$gio : ......................................................,$nis ua...........................: ..........................