FORMAT PENILAIAN

UJIAN PENGKAJIAN SEKUNDER (INITIAL ASSESSMENT)

KEPERAWATAN GAWAT DARURAT

Nama :
NIM :
Program :
No Item Penilaian Score (S) Bobot Jumlah
1 2 3 4 5 (B) (SXB)
1 Fase pra-rumah sakit 1

2 Fase rumah sakit 1

3 Triase 4

4 Primary survey 2
A. Airway
B. Breathing
C. Circulation
D. Disability
E. Environment

5 A. Airway and Cervical 2

Control
B. Breathing and
Ventilation
C. Circulation and
Hemorrhage control
D. Disability
E. Environment

6 SECONDARY SURVEY, 2
PEMERIKSAAN
PENUNJANG DAN
EVALUASI

7 Abdomen 2
8 Genetalia 2
9 Kaki 2
10 Punggung 2

NILAI AKHIR/TOTAL

Pekanbaru, ...........................
Penguji

( ........................................... )
Keterangan:
5 = Sangat memuaskan
4 = Memuaskan
3 = Cukup
2 = Kurang
1 = Gagal