Download as rtf, pdf, or txt
Download as rtf, pdf, or txt
You are on page 1of 7

Nama Mahasiswa : ……………………………………

Tanggal Pengkajian : ……………………………………

Jam Pengkajian : ……………………………………

I. Biodata Pasien
Nama : ………………………………………………………………..
Agama : ………………………………………………………………..
Pendidikan : ………………………………………………………………..
Pekerjaan : ………………………………………………………………..
Status Pernikahan : ………………………………………………………………..
Alamat : ………………………………………………………………..
………………………………………………………………..
………………………………………………………………..
………………………………………………………………..
Diagnosa Medis : ………………………………………………………………..

II. Alasan Masuk RS


………………………………………………………………………………………………….
………………………………………………………………………………………………….

III.Keluhan Utama
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….

IV. Riwayat Penyakit Sekarang


………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….

V. Riwayat Penyakit Dahulu


………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….

VI. Data Umum (DO, DS, Terapi)


………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
VII. Analisa Data

Nama Pasien : .............................................


Umur : .............................................
No.RM : .............................................

Data Masalah Penyebab

................................................................................. ............................................... ................................................................


................................................................................. ............................................... ................................................................
................................................................................. ............................................... ................................................................
................................................................................. ............................................... ................................................................
................................................................................. ...............................................
................................................................
................................................................................. ...............................................
................................................................................. ............................................... ................................................................
................................................................................. ............................................... ................................................................
................................................................................. ................................................................
................................................................................. ................................................................
................................................................................. ................................................................
................................................................................. ................................................................
.................................................................................
................................................................
.................................................................................
................................................................................. ................................................................
................................................................................. ................................................................
................................................................................. ................................................................
................................................................................. ................................................................
................................................................................. ................................................................
................................................................................. ................................................................
................................................................................. ................................................................
................................................................
................................................................
VIII. Diagnosa Keperawatan
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
IX. Catatan Perkembangan Keperawatan

Nama Pasien : .............................................


Umur : .............................................
No.RM : .............................................

No. Dx Waktu Implementasi Evaluasi Paraf


................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................................................................................. ...............................................................................
.................
................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................................................................................. ...............................................................................
.................
................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................................................................................. ...............................................................................
.................
................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
.................
.................
.................
No. Dx Waktu Implementasi Evaluasi Paraf
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................................................................................. ...............................................................................
.................
................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................................................................................. ...............................................................................
.................
................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................................................................................. ...............................................................................
.................
................................................................................. ...............................................................................
.................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................................................................................. ...............................................................................
.................
................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
................. ................................................................................. ...............................................................................
.................
.................
..................

You might also like