Asesmen Pasien Terminal Kolom

 

RUX PHROA]A OHMKJA Fn. Klmrajkna Li. 17 JHBXOHL - FAWA ]HLGAD ]hnp. 0247 - 547077;, Cax 54==14

AUHUOHL PAUKHL ]HROKLAN

MPFP 6 6  Lioir RO PPFP 6 6  Laoa Paskhl ]alggan Nadkr  6 Ashsohl awan talggan 6 ..................../ .................... .................... / .................... Pujun 6 ....... 6 ....... 1. Ghfana Ghfana yalg yalg ouleu ouleunn pama pama pask paskhl hl 1.1. Jhgawata Jhgawatal l phrlapas phrlapasal al □ Mysplhu □  Lapas ehpat mal malgjan □  Lapas naobat □  Lapas taj thratur  1.2. Jhdknalga Jhdknalgal l tilus itit itit □ Phlurulal phrghrajal tubud □ Uunkt bhrbkeara □ Uunkt ohlhnal 1.5. 1.5. Lyhr Lyhrkk ................................... □ [a, bhrupa ................................... 1.=. Phrnaoba Phrnaobatal tal skrjunask skrjunask

5.

=. 8.

3.

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 Lapas ohnanuk ounut Ama shjrht UpI2 > liroan ]kmaj ama jhnaklal

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Kljiltklhlska urkl Kljiltklhlska anvk ]kmaj ama jhnaklal

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]kmaj 

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□ ]hjalal marad ohlurul Bhreaj/skalisks pama hjstrhoktas Junkt mklgkl mal bhrjhrklgat □ □  Lamk naobat mal nhoad □ Ghnksad □ ]kmaj ama jhnaklal □ Nhoas Cajtir-c Cajtir-cajt ajtir ir yalg ohlklgj ohlklgjatja atjal l mal ohobalgj ohobalgjktja ktjal l ghfana ghfana ckskj 6 .................................................... .......... □ Nakl-nakl .......................................... □ Ohnajujal ajtkvktas ckskj  □ Pklmad pisksk Oalaf Oalafho hohl hl ghfa ghfana na saat saat klk klk 6 □ Jilstkpask □ Ouan □ Mhckskt phrawatal mkrk □ Pina lapas tkmaj hchjtkc  □  Lyhrk ajut □ Bhrskdal fanal lapas tkmaj hchjtkc  □  Lyhrk jrilks □ Phrubadal phrshpsk shlsirk Irkhltas Irkhltaskk spkrktuan spkrktuan paskhl paskhl mal jhnuarga. jhnuarga. Apajad Apajad phrnu phrnu phnayalal phnayalal spkrktua spkrktuan9 n9 ............................................... ....   □ ]kmaj □ [a, inhd ........................................... Xrusal mal jhbutudal jhbutudal spkrktuan spkrktuan paskhl paskhl mal jhnuarga shphrtk putus asa, asa, phlmhrktaal, phlmhrktaal, rasa bhrsanad atau phlgaopulal6 8.1. Phrnu Phrnu mkmiaja mkmiajal l6 □ ]kmaj  □ [a 8.2. Phrnu Phrnu bkobklgal bkobklgal ridalk ridalk 6 □ ]kmaj  □ [a 8.5. Phrnu Phrnu phlmaopklga phlmaopklgal l ridalk 6 □ ]kmaj  □ [a Utatus Utatus pkjisi pkjisiska skann mal mal jhnua jhnuarg rga a6 3.1. Apajad ama iralg iralg nakl yalg klgkl mkdubulgk saat saat klk9 □ ]kmaj  ................................................................... ............................................ ............................................ ................................... ............. □ [a, skapa ............................................. Dubulgal mhlgal paskhl shbagak ............................................ .................................................................. ......................................... ................... □

2.

□

 

Mkoala............................................................... Mkoala........................................ ............................................. ............................................ .......................................... ....................  Li. ]hnp/Li. DP............................ DP................................................... ............................................. ............................................ ....................................... ................. 3.2. Bagakoala rhleala phrawatal phrawatal shnalfutlya9 shnalfutlya9 □ ]htap mk rawat mk RU □ Mk rawat mk ruoad Apajad nklgjulgal ruoad sumad mkskapjal9 □ ]kmaj, apajad phrnu mkcasknktask mark RU □ [a, apajad ama yalg oaopu (diohearh )9 ohrawat paskhl mkruoad9 □ [a .......................... □ [a, inhd .......................... □ ]kmaj  □ ]kmaj 3.5. Rhajsk paskhl atas phlyajktlya 6 □ Rasa bhrsanad □ Ohlyalgjan □ Jhtkmajbhrmayaal □ Oarad □ Alskhtas □ ]ajut □ Mkstrhss spkrktuan □ Uhmkd/ohlalgks 3.=. Rhajsk jhnuarga jhnuarga atas atas phlyajkt phlyajkt paskhl6 paskhl6 Ashsohl klciroask □ Oarad □ Nhtkd/nhnad □

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Jhtkmajoaopual ohohludk phral yalg mkdarapjal

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Jhnuarga juralg bhrjioulkjask mhlgal Galggual tkmur   paskhl □ Rasa bhrsanad □ Jhnuarga juralg bhrpartkskpask ohobuat □ Phlurulal jilshltrask jhputusal manao phrawatal paskhl □ Phrubadal jhbkasaal pina jioulkjask 7. Jhbutudal mujulgal atau jhnilggaral phnayalal bagk paskhl, paskhl, jhnuarga jhnuarga mal phobhrk phobhrk phnayalal nakl 6 □ Uadabat mapat ohlgulfulgk paskhl mknuar □ Paskhl phrnu mkmaopklgk jhnuarga wajtu bhrjulfulg □ Jhnuarga mapat ohlgulfulgk paskhl ................................... □ Nakl-nakl ................................... mknuar wajtu bhrjulfulg 4. Apajad ama jhbutudal ajal anthrlatkc atau tklgjat phnayalal nakl 6 ............................ □ Milask irgal ............................ □ ]kmaj  ................................... □ Nakl-nakl ................................... □ Autipsk ;. Cajtir Cajtir rhskj rhskji i bagk bagk jhnuarg jhnuarga a yalg yalg mktklg mktklgganja ganjal l Ashsohl klciroask □ □ Oarad □ □ Nhtkd/nhnad □ □ Mhprhsk □ □ Galggual tkmur  □ Rasa bhrsanad

Mhlgal Mhlg al kl klkk ohly ohlyata ataja jal l ba badw dwaa saya saya thnad ohlhrkoa klciroask mal hmujask thrj thrjak aktt phnay hnayal alal al yal yalg mkb mkbhr hrkj kjal al jhpama saya shrta thnad ohoadaok mal ohlyhtufuklya.

6

Uhmkd/ohlalgks Phrubadal jhbkasaal pina jioulkjask Phlurulal jilshltrask Jhtkmajoaopual ohohludk phral yalg mkdarapjal

Jhnuarga Paskhl

Phrawat/Bkmal Phlgjafk

............................................... ]alma talgal & laoa thralg

............................................... ]alma talgal & laoa thralg