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IDENTITAS PASIEN
PASIEN PENANGGUNG JAWAB PASIEN
Nama :_______________________ Nama :_______________________
Umur :_______________________ Umur :_______________________
Agama :_______________________ Agama :_______________________
Pendidikan :_______________________ Pendidikan :_______________________
Perkerjaan :_______________________ Perkerjaan :_______________________
Status Pernikahan :_______________________ Status Pernikahan :_______________________
Alamat :_______________________ Alamat :_______________________
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RIWAYAT KESEHATAN
a. Keluhan Utama
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Hospitalisasi/tindakan operasi :
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Injuri/kecelakaan :
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Alergi :
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Pengobatan :
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d. Riwayat pertumbuhan :
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e. Riwayat sosial :
Yang mengasuh :
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f. Riwayat keluarga
Sosial ekonomi :
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Lingkungan rumah :
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Penyakit keluarga :
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Genogram :
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Bahasa :
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Motorik kasar :
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Interpretasi :
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FUNGSI KESEHATAN
POLA ELIMINASI
Sebelum Sakit Selama Sakit
Gambaran Diri :
Identitas Diri :
Peran Diri :
Ideal Diri :
Harga Diri :
POLA TOLERANSI STRES-KOPING
Sebelum Sakit Selama Sakit
PEMERIKSAAN FISIK
PENAMPAKAN UMUM
Keadaan umum
Kesadaran
GCS
TD : Suhu: RR : Nadi :
Palpasi :
Dikaji Oleh
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PEMERIKSAAN PENUNJANG
Waktu
Tgl dan Jenis Pemeriksaan Hasil Pemeriksaan
Jam
Waktu
Tgl dan Jenis Obat/ Nama Obat Dosis
Jam
ANALISA DATA
WAKTU
SYMPTOM/SIGNS ETIOLOGI PROBLEM
TGL/JAM
DIAGNOSA KEPERAWATAN DAN PRIORITAS MASALAH
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Hari Ke:
Ttd
(Nama terang)
Hari Ke:
Hari Ke:
Ttd
(Nama terang)