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  • Follow Up

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    Yohana Kifli
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    The document contains a medical examination report template consisting of sections for patient identification, medical history, vital signs, examination of head, neck, chest, abdomen, extremities, neurological status, assessment, and plan. The template includes fields for room/ward, attending physician, status, admitting diagnosis, name, date of admission, chief complaint, examination findings, assessments, and prescribed treatments.

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    follow up

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    The document contains a medical examination report template consisting of sections for patient identification, medical history, vital signs, examination of head, neck, chest, abdomen, extremities, neurological status, assessment, and plan. The template includes fields for room/ward, attending physician, status, admitting diagnosis, name, date of admission, chief complaint, examination findings, assessments, and prescribed treatments.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    11 views1 page

    Follow Up

    Uploaded by

    Yohana Kifli
    The document contains a medical examination report template consisting of sections for patient identification, medical history, vital signs, examination of head, neck, chest, abdomen, extremities, neurological status, assessment, and plan. The template includes fields for room/ward, attending physician, status, admitting diagnosis, name, date of admission, chief complaint, examination findings, assessments, and prescribed treatments.

    Copyright:

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

    Lt/ruang: DPJP: Status: Lt/ruang: DPJP: Status:

    PJ koas: RM: Kelas: PJ koas: RM: Kelas:


    Bed: Usia: Diagnosa: Bed: Usia: Diagnosa:
    Nama: Tgl Masuk: Nama: Tgl Masuk:
    S: S:

    O: KU: O: KU:
    TD: HR: S: RR: SpO2: TD: HR: S: RR: SpO2:
    Mata: CA: SI: Mata: CA: SI:
    Leher: KGB: JVP: Leher: KGB: JVP:
    Thoraks:SNV: Rh: Wh: Thoraks:SNV: Rh: Wh:
    BJ1,2: M: G: BJ1,2: M: G:
    Abd: Supel: BU: NT: Abd: Supel: BU: NT:
    Ekst: AH: Oe: Ekst: AH: Oe:
    Status neurologis Status neurologis
    GCS: E M V= CM/...... GCS: E M V= CM/......
    Pupil: Isokor/Tdk Ø mm/ mm Pupil: Isokor/Tdk Ø mm/ mm
    RCL: RCTL: RCL: RCTL:
    R.Fisiologis: R.Patologis: R.Fisiologis: R.Patologis:
    Rangsang Meningeal: Rangsang Meningeal:
    Motorik: Motorik:

    (dll: contoh: parese N.VII) (dll: contoh: parese N.VII)


    A: A:

    P: P:

    Lt/ruang: DPJP: Status: Lt/ruang: DPJP: Status:


    PJ koas: RM: Kelas: PJ koas: RM: Kelas:
    Bed: Usia: Diagnosa: Bed: Usia: Diagnosa:
    Nama: Tgl Masuk: Nama: Tgl Masuk:
    S: S:

    O: KU: O: KU:
    TD: HR: S: RR: SpO2: TD: HR: S: RR: SpO2:
    Mata: CA: SI: Mata: CA: SI:
    Leher: KGB: JVP: Leher: KGB: JVP:
    Thoraks:SNV: Rh: Wh: Thoraks:SNV: Rh: Wh:
    BJ1,2: M: G: BJ1,2: M: G:
    Abd: Supel: BU: NT: Abd: Supel: BU: NT:
    Ekst: AH: Oe: Ekst: AH: Oe:
    Status neurologis Status neurologis
    GCS: E M V= CM/...... GCS: E M V= CM/......
    Pupil: Isokor/Tdk Ø mm/ mm Pupil: Isokor/Tdk Ø mm/ mm
    RCL: RCTL: RCL: RCTL:
    R.Fisiologis: R.Patologis: R.Fisiologis: R.Patologis:
    Rangsang Meningeal: Rangsang Meningeal:
    Motorik: Motorik:

    (dll: contoh: parese N.VII) (dll: contoh: parese N.VII)


    A: A:

    P: P:

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