Rumah Sakit Umum Daerah Nomor RM :

I.A. Moeis Samarinda Nama Lengkap :

Jalan H.A.M.M. Rifaddin Tanggal Lahir/Umur :
Samarinda
Telp. (0541) 7030423
e-mail : rsud_iam@yahoo.com

ASESMEN PRA BEDAH

Tanggal asesmen : ________ pukul: ______________ oleh: ____________ data diperoleh dari: __________________________

Asal Pasien : IGD Poliklinik Rujukan dari luar dokter/klinik Ruang Perawatan Lain-lain _________________

Asesmen Medis Pra Operasi (diisi oleh dokter)

1. Anamnesis :
a. Keluhan Utama : ________________________________________________________________
b. Riwayat penyakit sekarang : ________________________________________________________________
c. Riwayat penyakit dahulu : ________________________________________________________________
d. Riwayat operasi sebelumnya : Tidak ada Ada, Jika ada operasi ________________ ,tahun ___________
e. Riwayat penyakit keluarga : ________________________________________________________________
f. Riwayat penggunaan obat : ________________________________________________________________
g. Riwayat alergi obat/makanan/lain-lain : ___________________________________________________________
2. Pemeriksaan fisik dan status generalis :
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3. Pemeriksaan penunjang/diagnostik :
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4. Diagnosis pra operasi : ___________________________________________________________________________
5. Rencana tindakan dan pengobatan : _ ________________________________________________________________
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Perencanaan Pulang : _____________________________________________________________________________
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Diisi oleh dokter yang melakukan pengkajian Tanda tangan & Nama Jelas

Tanggal dan pukul selesai :