Professional Documents
Culture Documents
.........................................................................................................................................
................................................................................................................
Nama Mahasiswa
: ......................................................
NIM
: ......................................................
Tanggal Pengkajian
: ......................................................
1. Pengkajian
A. Identitas Pasien
Nama
: ..........................................................................
Umur
: ..........................................................................
Jenis Kelamin
: ..........................................................................
Pendidikan
: ..........................................................................
Suku Bangsa
: ..........................................................................
Pekerjaan
: ..........................................................................
Agama
: ..........................................................................
Status Perkawinan
: ..........................................................................
Alamat
: ..........................................................................
: ..........................................................................
Ruang Rawat
: ..........................................................................
B. Penanggung Jawab
Nama
: ..........................................................................
Umur
: ..........................................................................
Pekerjaan
: ..........................................................................
Alamat
: ..........................................................................
: ..........................................................................
Jam masuk RS
: ..........................................................................
Yang mengirim/merujuk
: ..........................................................................
Alasan masuk
: ...........................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
....
Diagnosa medis saat masuk
: ..........................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
F. Riwayat Kesehatan keluarga
......................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
Genogram
Keterangan:
......................................................................................................................
......................................................................................................................
2) Sakit :
......................................................................................................................
......................................................................................................................
5. Personal Hygiene
1) Sehat :
...................................................................................................................
...................................................................................................................
2) Sakit :
...................................................................................................................
...................................................................................................................
I. Pemeriksaan fisik
Tanggal : .......................................
1. Umum
Keadaan umum
: ......................................................................................
Tingkat kesadaran : ......................................................................................
Tinggi badan
: ......................................................................................
Berat badan
: ......................................................................................
2. Tanda- tanda vital
Suhu
: ......................................................................................
Nadi
: ......................................................................................
Pernafasan
: ......................................................................................
Tekana darah
: ......................................................................................
3. Rambut dan kepala
Inspeksi
: ..................................................................................................
..................................................................................................
..................................................................................................
Palpasi
: ..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
4. Mata
Inspeksi
5. Telinga
Inspeksi
: ..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
: ..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
6. Hidung dan sinus
Inspeksi
: ..................................................................................................
Palpasi
7. Mulut
Inspeksi
8. Leher
Inspeksi
Palpasi
..................................................................................................
..................................................................................................
..................................................................................................
: ..................................................................................................
..................................................................................................
: ..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
: ..................................................................................................
..................................................................................................
: ..................................................................................................
..................................................................................................
9. Thorak
1. Paru
Inspeksi
Palpasi
Perkusi
Auskultasi
2. jantung
Inspeksi
Palpasi
Perkusi
: ......................................................................................
......................................................................................
: ......................................................................................
: ......................................................................................
: ......................................................................................
: ......................................................................................
: ......................................................................................
: ......................................................................................
......................................................................................
......................................................................................
: ......................................................................................
Auskultasi
10. Abdomen
Inspeksi
: ..................................................................................................
Ausklultasi : ..................................................................................................
Palpasi
: ..................................................................................................
..................................................................................................
Perkusi
: ..................................................................................................
11. Genetalia
Inspeksi
: ..................................................................................................
12. Ekstremitas
1. Atas
Inspeksi
: ......................................................................................
Palpasi
2. Bawah
Inspeksi
Palpasi
......................................................................................
......................................................................................
: ......................................................................................
......................................................................................
: ......................................................................................
......................................................................................
......................................................................................
: ......................................................................................
......................................................................................
K. Program Dokter