MODUL PRAKTIKUM

ASSESMEN DAN DIAGNOSA FISIOTERAPI

STATUS KLINIK

A.​ D
​ ATA-DATA MEDIS RUMAH SAKIT

a. Diagnosa medis :................................................................................................................

b. Catatan Klinis :................................................................................................................
c. TerapiUmum :…………………………………………………………………………

B.​ P
​ EMERIKSAAN FISIOTERAPI

1. Anamnesis
a. Anamnesis Umum
Nama :................................................................................................................
Umur :........................................................................................(Mgg/Bln/Thn)
Alamat :................................................................................................................
................................................................................................................
Jenis kelamin :(L/P)
Agama :................................................................................................................
Pekerjaan :................................................................................................................
b. Anamnesis Khusus
Keluhan Utama :.............................................................................................
.............................................................................................
.............................................................................................
Riwayat penyakit :.............................................................................................
.............................................................................................
.............................................................................................
Riwayat penyakit dahulu :.............................................................................................
.............................................................................................
.............................................................................................
Riwayat penyakit penyerta :.............................................................................................
.............................................................................................
c. Anamnesis Sistem
1) Musculoskeletal :..............................................................................................
2) Kardiovaskuler :..............................................................................................
3) Respirasi :..............................................................................................
4) Neuromuscular :..............................................................................................
2. Pemeriksaan Fisik
a. Vital Sign
● Tekanan Darah :..................................................................................
● Denyut Nadi :..................................................................................
● Pernapasan :..................................................................................
● Temperatur :..................................................................................
b. Inspeksi
● Statis :..................................................................................
● Dinamis :..................................................................................
3. PemeriksaanSpesifik
a. MMT :

b. Tes Tonus otot :

c. TesKeseimbangan:

d. PengukuranNyeri:

e. Tes Koordinasi
f. TesApresiasiReaksi :
g. Tessensorik :
h. Tes Reflek :
 i. Tes Rasa Posisi:
j. Tes Transfer:

k. TesADL:
4. Kognitif,intrapersonal, dan interpersonal
Kognitif :
Intrapersonal :
Interpersonal :

C.​ D
​ IAGNOSIS FISIOTERAPI :..............................................................................................
..............................................................................................

D. PROBLEMATIK FT :..............................................................................................
..............................................................................................
...............................................................................................

E. PROGRAM RENCANA TINDAKAN FISIOTERAPI

1. Tujuan jangka panjang :……………………………………………………………..
……………………………………………………………...
……………………………………………………………...
……………………………………………………………...
2. Tujuan jangka pendek :……………………………………………………………..
……………………………………………………………...
……………………………………………………………...
……………………………………………………………...

F. INTERVENSI FISIOTERAPI
…………………………………………………………………………………………………………
…………………………………………………………………………………………………
 …………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
……………………………………………………………………………………..........
G. PROGNOSIS
Quo ad vitam :................................................................................................................
Quo ad sanam :................................................................................................................
Quo ad fungsionam :................................................................................................................
Quo ad cosmeticam :................................................................................................................

H. EVALUASI
1) Evaluasi sesaat :…………………………………………………………………............
………………………………………………………………………….
………………………………………………………………………….
………………………………………………………………………….

2) Evaluasi berkala :…………………………………………………………………………

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

I. HASIL TERAPI AKHIR

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

J. HOME PROGRAM
…………………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………….........
K. UNDERLIYING PROCESS
…………………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………..………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………