Asesmen Igd 5r5p3h
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III. PENGKAJIAN MEDIS Pemeriksaan Dokter, Pukul : Subjective : ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Objective : ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Pemeriksaan Penunjang :
□ EKG : _____________________________________________________________________ □ Radiologi : _____________________________________________________________________ □ Laboratorium : _____________________________________________________________________ Assessment :
□ Diagnosa Kerja □ Diagnosa Banding
: _______________________________________________________________ : _______________________________________________________________ _______________________________________________________________
Palanning : Penatalaksanaan / Pengobatan / Rencana Tindakan / Konsultasi ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
__________________________ Nama / Tanda Tangan Dokter
____________________________________________________________________________________ ____________________________________________________________________________________
□ EKG : _____________________________________________________________________ □ Radiologi : _____________________________________________________________________ □ Laboratorium : _____________________________________________________________________ Assessment :
□ Diagnosa Kerja □ Diagnosa Banding
: _______________________________________________________________ : _______________________________________________________________ _______________________________________________________________
Palanning : Penatalaksanaan / Pengobatan / Rencana Tindakan / Konsultasi ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
__________________________ Nama / Tanda Tangan Dokter
____________________________________________________________________________________ ____________________________________________________________________________________
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