contoh pengisian rekam medis IGD

RS WAVA HUSADA Jl.Panglima Sudirman 99A Kepanjen-Malang Telp.0341-393000 Fax.0341-398398	No.Rekam Medis :
	Nama               : Ny. S  L / P Tanggal lahir   :  2 Mei 1965 Umur               : 50 Tahun *Tempel stiker identitas jika ada
REKAM MEDIS INSTALASI GAWAT DARURAT

I.PENGKAJIAN MEDIS (DIISI OLEH DOKTER)

Tanggal : 22 juni 2015....................    Jam : 11.30................ WIB

Informasi di dapat dari	Ö  Pasien   Keluarga    Nama : ....................................... Hubungan : ..............................
Cara Masuk	Ö  Jalan tanpa bantuan      Jalan dengan bantuan    Kursi Roda    Tempat tidur dorong/Brankat
Asal Masuk	Ö  Non Rujukan    Rujukan  .....................
Triase	Jenis Kegawatan :   P1        Ö P2         P3         P0
Keluhan Utama	Diare
Riwayat Penyakit Sekarang	Klien mengeluh diare selama 2 hari dan badan terasa lemas, BAB encer berlendir dengan frekuensi 4-5 kali setiap harinya. Dan klien mengatakan “sebelumnya makan-makanan pedas”
Riwayat Penyakit dahulu/pengobatan sebelumnya	Tidak ada............................................................................................................................................................... ...............................................................................................................................................................................
Riwayat penyakit keluarga	Tidak ada................................................................................................................................................................
Riwayat Alergi	Tidak ada................................................................................................................................................................
Status psikologi,sosial,spiritual,ekonomi	Konsep diri          : Baik..................................................    Kegiatan ibadah  : Baik........................................ Tinggal bersama : Keluarga...........................................    Pekerjaan            : ibu rumah tangga..................
Status Kehamilan	Ö Tidak Hamil      Hamil, Gravida : ............ Para : ........... Abortus : ............ HPHT : .............
Tanda-tanda vital	GCS   : E 4          V 5        M 6                    Ket         : compos mentis
	TD    : 80                   / 50            mmHg	Nadi     : 98             x/mnt           (Reguler/Ireguler)
	RR    : 20                                      x/menit	Suhu     :37,5           °C
	SPO2 : 96                   %	Akral    :
	BB     : 55                   Kg	TB        : 150           cm
	Reflek Cahaya :                  /	Pupil     :                      mm/                         mm
	Ket. Lain  :
Pemeriksaan Fisik Badan klien panas, warna dan bau feses khas................................................................... ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ..... Kode Gambar : ............................................................................................................................................. ..... A       : Abrasi                                   U     : Ulkus ............................................................................................................................................. ..... C       : Combustio                        H     : Hematoma ............................................................................................................................................. ..... VA    : Vulnus Appertum         N     : Nyeri ............................................................................................................................................. ..... D      : Deformitas                        L      : Lain-lain
Pengkajian Nyeri	WONG BAKER FACES PAIN RATING SCALE UNTUK ANAK <6 tahun NUMERIC RATING SCALE (NRS) UNTUK ANAK ≥ 6 TAHUN DAN DEWASA   0             1              2               3               4               5                6               7              8           9            10               Tidak nyeri          Nyeri Ringan                            Nyeri Sedang                                       Nyeri Berat Total sore      :                               Lokasi   :            Skala Nyeri    :                                 Tidak Nyeri       Nyeri ringan      Nyeri Sedang      Nyeri Berat
Pengkajian resiko pasien jatuh	Score : .........................   Ö Rendah   Sedang   Tinggi
Pengkajian Nutrisi	Apakah BMI <20,5 ?             Ya            Tidak
Pemeriksaan penunjang	 EKG                     :   Radiologi             :   Laboratorium      :   Pemeriksaan lain                                :
Assesmen	Diagnosis Kerja (Work Diagnosis):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Diagnosis Banding (Differential Diagnosis): ........................................................................................................                                                                      ..........................................................................................................                                                                      ..........................................................................................................
Planning	Penatalaksanaan/Pengobatan/RenCana Tindakan/Konsultasi ............................................................................................................................................................................... ............................................................................................................................................................................... ............................................................................................................................................................................... ............................................................................................................................................................................... ............................................................................................................................................................................... ............................................................................................................................................................................... ............................................................................................................................................................................... ............................................................................................................................................................................... ...............................................................................................................................................................................
Dokter Sepesialis (DPJP)

Dokter IGD

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