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  • Rekam Medis Dokter: Tanggal: Jam

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    This medical record document contains sections for subjective and objective patient information, assessment, and treatment plan. It includes fields for vital signs, physical exam findings, lab results, diagnoses, differential diagnoses, therapies, procedures, education, follow up, and referrals. There are also sections for nursing or midwifery care plans, assessments, and interventions.

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    rekam medis

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    Bela Kang

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    This medical record document contains sections for subjective and objective patient information, assessment, and treatment plan. It includes fields for vital signs, physical exam findings, lab results, diagnoses, differential diagnoses, therapies, procedures, education, follow up, and referrals. There are also sections for nursing or midwifery care plans, assessments, and interventions.

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    4 views1 page

    Rekam Medis Dokter: Tanggal: Jam

    Uploaded by

    pkm jonggon
    This medical record document contains sections for subjective and objective patient information, assessment, and treatment plan. It includes fields for vital signs, physical exam findings, lab results, diagnoses, differential diagnoses, therapies, procedures, education, follow up, and referrals. There are also sections for nursing or midwifery care plans, assessments, and interventions.

    Copyright:

    © All Rights Reserved
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    of 1

    REKAM MEDIS DOKTER

    Tanggal : Jam :
    SUBJEKTIF OBYEKTIF ASSESMENT PLAN Tanda
    (KEL – RPS – RPD – RPK) (VS – PEM.FISIK – LAB – Penunjang) (DIAGNOSA – DD) (Terapi – Tindakan – Edukasi – Tangan
    Kontrol – Rujukan) Dokter
    LAB
    GDS : mg/dl
    GDP : mg/dl
    Kol. Total : mg/dl
    Asam Urat : mg/dl
    HB : %
    Urin :
    BTA :

    KU : CM / Apatis / Somnolen / Stupor / Koma


    Kepala : Normosefal / Mesosefal
    Mata : Konj. Dbn / Anemi / abses / Benjolan / sklera
    Putih / Ikterik / hiperemis
    Telinga : dbn / cairan / darah / serumen / corpus alienum
    MT : Intak / perforasi
    Hidung : dbn / dev.sept / darah / lendir / co.al / nch +/-
    Bibir : dbn / pucat / sariawan
    Mulut : lidah kotor / fissura / dbn Tanda
    Faring : dbn / hipermis / membran abu2/ nanah Tangan
    Klien
    T.../T... , LEHER : Dev. Trachea / tiroid -/+
    KGB (-)/ + >> Retraksi dada +/-
    Paru : vesikuler / Ronchi / wheezing
    Jantung : SJ Murni / murmur / galloop
    Abdomen : dbn / NT ulu hati (-) (+), massa / venektasi def.
    Musc / hipertimpani / BU (+) N
    Ekstremitas : Sup / Inf : dbn / edema / akral dingin / ulkus /
    gangren / gangguan kulit

    ASUHAN KEPERAWATAN / ASUHAN KEBIDANAN


    DATA DATA DIAGNOSA RENCANA KEPERAWATAN/ Tanda
    SUBYEKTIF OBYEKTIF KEPERAWATAN / RENCANA KEBIDANAN Tangan
    KEBIDANAN Perawat/
    Bidan
    TD :
    Nadi :
    RR :
    S :

    TB :
    BB :
    LP :

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