PEMERINTAH KOTA SIBOLGA NO.

RM :
RSU DR. FERDINAND LUMBANTOBING
NAMA : ..................................
ASESMEN MEDIS RAWAT JALAN UMUR : ...........................
PASIEN PENYAKIT DALAM .......
ALAMAT : ..................................
DPJP :..................................................................... PPJP : ...........................................................
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Di isi oleh Dokter

TANGGAL : :................................

A. ANAMNESA
1. Keluhan Utama :
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2. Riwayat Penyakit Dahulu :
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3. Riwayat Penyakit Sekarang :
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4. Riwayat Penyakit Keluarga :
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B. PEMERIKSAAN FISIK.
1. Vital Sign :
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2. Cranium :
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3. Leher :
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4. Thorax :
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 5. Abdomen :................................................................................................................................
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6. Genitalia : ...............................................................................................................................
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7. Extremitas :

a. Ext. Atas : ............................................................................................................................

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b. Ext. Bawah : .........................................................................................................................
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C. DIAGNOSTIK PENUNJANG.

1. Laboratorium :...........................................................................................................................
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2. Radiologi : ................................................................................................................................
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3. USG................................................................................................................................
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4. EKG................................................................................................................................
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D. DIAGNOSA BANDING:
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E. DIAGNOSA KERJA :

E. THERAPI. : ....................................................................................................................................
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Dokter Penanggung Jawab Pasien

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