14. Cm 10.docx

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PUSKESMAS KELIMUTU Nama

CM 10

:

Nomor : Umur

Ruangan : Tanggal :

:

Jam:

Dokter :

STATUS PASIEN Suhu

°C

:

Pernapasan :

Nadi :

kali/menit

BB :

kali/menit kg

Keadaan Umum : Kesadaran

:

GCS

:

Kepala : Mata :

Gizi

:

Kulit

Leher

:

Telinga :

Hidung :

Tengkorak :

Mulut /Gigi Geligi : Dada – lambung : -

Paru-paru :

Perut hati :

Limpa :

Alat kelamin : Anggota Gerak :

PEMERIKSAAN LABORATURIUM - Darah : HB : Leokosit : DDR : KESIMPULAN SEMENTARA :

Refleks :

:

TD :

mmHg

TB :

cm

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