Rekam Medis Ugd - Puskesmas

No :

KARTU UNIT RAWAT DARURAT PUSKESMAS ………………

Tanggal :

Hari :

Datang

:

Jam :

Ambulance/ Ambulanc e/ en!iri / Diantar oleh "elaurga / Tetangga / Teman / Poli#i

IDENTITAS IDENT ITAS PASIEN :

Nama

: ........................... ............. ............................. ................. ..

$mur

:

Agama

: ........................... ............. ............................. ................. ..

Alamat

: ........................... ............. ............................. .............................. .................. ...

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

La(i / 7anita 7anita

Tele+on : ........................ ............. ...........

IDENTITAS IDEN TITAS PENGANTAR PENGAN TAR PASIEN :

Nama

: ............................. .............. .............................. ...............

$mur

: ..................... .............. ....... La(i / 7anita

Agama

: ............................ .............. ............................. .................

Alamat

: ............................ .............. ............................. .............................. ................. ..

Tele+on : ........................ ............... .........

ANAMNESE :

"eluhan $tama

:

%i&a'at Pen'a(it #ebelumn'a #ebelum n'a : PEMERIKSAAN FISIK :

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

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

Lainn'a : .....................................................................................................

"$

"e+ala

:

"e#a!aran : )* / A+a,# / e+oro# / "omatu# / "oma T : ...................*m ............. ......*m Hg N : .................. ............... ... / mm  : ..........................  : ................... ................... ) P : .................. ................ .. / mm T : .......................... ............. ............. : *ata : )e(ung 0/-1 )on2u(,a Anemi# : 0/-1 (elera 4(teru# 0/Pu+il : 4#o(or 4#o(or (i !an (a 0/*i!ria#i# / *io#i# $(uran ..........cm ..........cm %ee(# caha'a (i 0/-1 0/-1 (a 0/Lain-lain : ......................................................................................................

3. L e h e r

:

Thora

: -

Lain-l Lain-lain ain 6(#t 6(#tre remi mita ta##

JPV. JPV. 5 ± : .................... .............................. ..................... ....................... ....................... ..................... ..................... ...................... .................. ....... Lain-lain : ....................................................................................................... Jantung : un'i 4 !an 44 Jela#/Ti!a(1 un'i Tambahan 0/-1 *urmur 0/- Paru : %on(hi ba#ah halu# / (a#ar / n'aring / ta( n'aring %on(hi "ering 0/: ..... ........ ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ..... ..... ...... ...... ...... ...... ...... ...... ...... ...... ...... ..... ..... ...... ...... ...... ...... ...... ...... ..... .. : ian iano# o#i# i# 0/-1 0/-1 )lub )lubin ing g 0/-1 0/-1 Jari Jari (eri (eri+u +utt 0/0/Ding Dingin in 0/0/6!ema 0/-1 en!i beng(a( 0/- !i ............ ..................... .................... ..................... .................... .................... ............ .. Para+are#e Para+are#e 0/- u+erior / 4nterior1 4nterior1 Hemi+are#e 0/- (iri / (anan

Ab!omen

:

Datar / )e(ung / "embung / Lema# / Tegang N'eri te(an 0/De8an# *u#coler 0/-1 Turgor Normal / Turun elotemen 0/-1 i#ing $#u# : 9 / - / normal / n /  /  He+ar ,!a( teraba / membe#ar ............................ ................................. ..... 2+ ..............................2+a "en'al / Luna( / "era# / %ata / Ti!a( %ata N'eri Te(an Te(an 0/Lim+a : ............................. .............. ............................. ................ ;in2al : ............................. .............. ............................. ................ "an!ung "encing : .............................. ............... ................. .. Lain-lain : ............................. .............. ............................. ................ "emam+uan "emam+uan : ;) : 6 ........ ............ ........ ........ ........ ........ ...... .. * : ........ ............ ........ ........ ........ ........ ....... ... V : ........ ............ ........ ........ ........ ........ ........ ...... Pemeri(#aan Tambahan

:

-

Laboratorium :

-

Foto Ronggent

:

-

USG Abdomen

:

-

EKG

:

-

Lain – lain

:

9. Luka Luka – luka luka