I. IDENTITAS PASIEN
Nama :...................................................................................................
No Rekam Medis : ..................................................................................................
Tempat/ tanggal lahir : ..................................................................................................
Umur : ..................................................................................................
Jenis Kelamin : ..................................................................................................
Suku bangsa : ..................................................................................................
Bahasa yang dimengerti : ..................................................................................................
Agama : ..................................................................................................
Nama Ayah/ Ibu/ wali : ..................................................................................................
Pendidikan ayah/ibu/wali : ..................................................................................................
Pekerjaan ayah/ibu/wali : ..................................................................................................
Alamat/ no telp : ..................................................................................................
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Diagnosa medis : ..................................................................................................
Tanggal MRS : ..................................................................................................
V. RIWAYAT PERTUMBUHAN
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d. Motorik kasar
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VII. RIWAYAT SOSIAL
a. Pengasuh : .......................................................................
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b. Pembawaan secara umum : .......................................................................
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c. Hubungan dengan anggota keluarga : .......................................................................
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d. Hubungan dengan teman sebaya : .......................................................................
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c. Aktifitas
Kemampuan Perawatan Diri 0 1 2 3 4
1. Makan dan Minum
2. Mandi
3. Toileting
4. Berpakaian
5. Berpindah
Keterangan : 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang
lain dan alat, 4 = tergantung total
e. Telinga
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f. Hidung
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g. Mulut
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h. Leher
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i. Dada
Paru-paru
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Jantung
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j. Abdomen
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k. Genetalia
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l. Ekstrimitas
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m. Neurologi
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XI. PEMERIKSAAN DIAGNOSTIK PENUNJANG
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XIII. INFORMASI LAIN (mencakup rangkuman kesehatan klien dari gizi, fisioterapis, dll)
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XVIII.
EVALUASI
Hari / Tgl
No No Dx Evaluasi TTD
/ Jam
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Mahasiswa
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NIM :.......................................