Tanggal:

Nama pasien Umur/ jenis kelamin Bangsal/ RM No. bed

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A. Status Generalis1.2. Keadaan umun: (E V M )3. Suhu badan : oC4. Respirasi : x/menit

5. Nadi : x/menit 6. Tekanan darah : / mmHg

B. Status Interna1. Kepala/ leher : CA( / ), SI( / ), PKGB( / )2. Jantung : BjI-II ( ), bising ( )3. Paru-paru : SDV( ), Wheezing ( ), Ronchi ( )4. Abdomen : 5. Ekstremitas :

C. Assessment

D. Planning

E. Pemeriksaan penunjangEKG :

USG :

ImunologiHbSAg :Anti HCV :HIV test :

Laboratorium gula darahGDA :

GDP :2PP :

Pemeriksaan darah lengkap

WBC : (4-10)

Lymph#: (0.8-4.0)

Mid# : (0.1-1.5)

Gran# : (2.0-7.0)

Lymph%: (20-40)

Mid% : (3-15)

Gran% : (50-70)

HGB : (11-16)

RBC : (3.5-5.5)

HCT : (37-54)

MCV : (60-100)

MCH : (27-34)

Tanggal:

MCHC : (32-36) PLT : (100-300)

Pemeriksaan kimia

darah

DBIL : (0-0.35)

TBIL : (0.2-1.2)

SGOT : (0-38)

SGPT : (0-40)

ALP : (98-729)

GamaGT: (10-54)

TP : (6.6-8.3)

ALB : (3.5-5.5)

Glob : (2-3.9)

UREA : (10-50)

CREAT : (0.7-1.4)

UA : (3.4-7)

CHOL : (140-200)

TG : (36-165)

HDL : (35-160)

LDL : (0-190)

Na : (135-148)

K : (3.5-5.3)

Cl : (98-107)

Ca : (8.1-10.4)

Mg : (1.9-2.

Pemeriksaan urin lengkap

Warna :

pH :

B. jenis :

Protein :

Keton :

Urobilin:

Bilirubin:

Sedimen

Leukosit:

Eritrosit:

Jamur :

Bakteri :

Kristal :

F. Pemeriksaan penunjang lainnya

G. Keterangan

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Tanggal:

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