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PEMERINTAH KABUPATEN KUDUSRSUD dr. LOEKMONO HADIJl. dr. Lukmonohadi No. 1

T!l". #$%1& '''$$1 Kudu( )*'+ASUHAN GIZI

No. RM ,

Nama ,

Alama- ,

Umur ,

INSTALASI I/I Ruan0 ,

1. ASESMEN GIZI LANJUT

Riwayat Makan & Obat SebelumAwal !i RSRiwayat "enyakit "eme#ik$aan %i$ik lini$

Bahan Makanan URT r!k 2 hr

Makanan Pokok , Al!r0i , Anor!k(ia ,

Lauk H!3ani , Hi"!r-!n(i2(-rok! , Saki- i0i 2 Mulu- ,Lauk Na4a-i , Hi"!rli"id!mia , Saria3an ,

Sa5ur , Hi"!ruri(!mia , Saki- "!ru- ,

Buah , Hi"!rur!mia , Suli- m!n0un5ah ,

Sna6k , Hi"!r6r!a-inin , Suli- m!n!lan ,

Air "u-ih 2 7ormula , Hi"!r0lik!mia , Hau( 2 d!hidra(i ,

T!h 2 ko"i , In7!k(i "aru , Mual 2 mun-ah ,

So7- 2 ("or- drink , Jan-un0 , O!d!ma 2 a(6i-!( ,

Minuman h!r4al , In7!k(i ha-i , An!mi( 2 l!mah ,

O4a- 8 o4a-an , B!dah (al. 6!rna , Ram4u- -i"i( ,

Pan-an0an , Kon(-i"a(i , A-ro"i o-o- ,

Pua(a Khu(u( , Di("!"(ia , Kuli- 4!r(i(ik ,

Kon(um(i E , kkal2hr #............9& P!n5aki- 0in:al , Tr!mor 2 "u(in0 ,

P , 0r2hr #............9& Kank!r , Am4ulan(i ,

L , 0r2hr #............9& In7!k(i (al. 6!rna , To-al 4!d r!(- , KH , 0r2hr #............9& ............................ , ;;;;;;. ,

"eme#ik$aan Ant#'('met#i "eme#ik$aan )i'kimia* Te$ Me!i$ !an Tan!a +ital

BB Ak-ual #k0& , Kol!(-!rol , SOT ,

BB Id!al #k0& , LDL , SPT ,

TB #6m& , HDL , Al4umin ,

Lin0kar L!n0an A-a( #6m& , Tri0i(!rida , T!kanan darah ,

Lin0kar O-o- L!n0an A-a( #6m& , A(am ura- , Nadi ,

T!4al L!mak Ba3ah Kuli- #mm& , Ur!um , Suhu ,

Lin0kar Pin00an0 2 Pan00ul , ........................................

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In$tala$i Gi4iRSU- !# L'ekm'n' Ha!i u!u$

-A%TAR -IET "ASIEN RUANG RA5AT INA"

HARI , ................................ RUANG , ....................................

TANGGAL ,................................. JUMLAH , ....................................

NO NAMA "ASIEN NO. RM AMAR LS

JENIS -IET -AN )UTI "EN7AJIAN E"A-A "ASIENETERANGAN

"AGI "ARA%AG

"ARA%"ASIEN

SIANG "ARA%AG

"ARA%"ASIEN

SORE "ARA%AG

"ARA%"ASIEN

P!-u0a( P!n5a:i Makanan # P!n0irim & .................... ................... .....................

P!-u0a( P!ra3a- # P!n!rima & .................... ................... .....................

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PEMERINTAH KABUPATEN KUDUSRUMAH SAKIT UMUM DAERAH

Jl. dr. Lukmonohadi No. 1T!l". #$%1& '''$$1 Kudu( )*'+

ASUHAN GIZITERSTAN-AR

NO. RM ,

Nama ,

Umur ,

J!ni( K!lamin ,

INSTALASI I/I Ruan0 2 Kl( ,

RE

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2 Kuran0

L!mak , 0r L!mak , 9 L!4ih 2 .............................................

NUTRISIONIS 2 DIETISIEN

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