IDENTITAS
Nama : ___________________________
ASESMEN AWAL Tgl lahir : _______________________ L / P
KEPERAWATAN RAWAT JALAN Alamat : __________________________
No. RM No Tlp pasien : __________________________
Agama : __________________________
RSUD SOREANG ____________________ Suku Bangsa : ___________________________
Jl. Alun-Alun Utara No.1 Soreang 40912 Telp. (022)
5891355 Fax: 5896592 Pendidikan : ___________________________
I. ALERGI / REAKSI
Tidak ada alergi
Alergi obat, sebutkan
........................................................reaksi .................................................
Alergi makanan, sebutkan ................................................reaksi .................................................
Alergi lainnya, sebutkan ....................................................reaksi ................................................
Gelang tanda alergi dipasang (warna merah )
Tidak diketahui
V. RIWAYAT HAID
...........................................................................................................................................................
...........................................................................................................................................................
VI. RIWAYAT KB
...........................................................................................................................................................
DATA OBJEKTIF
XI. STATUS GENERALIS
Keadaan umum :...........................Kesadaran :......................... BB .. Kg TB : Cm
Gizi : .Nadi : . X / mnt Tensi : .. mmHg Suhu :
..c respirasi : . X / mnt
RM 006 b 3 / RI / RSD
Presentasi : .......... .......... . Lain-lain: .......... .
Punggung : .......... ..........
BJJ : .......... ..........
HIS : .......... ..........
XIX.ANALISA DATA
...........................................................................................................................................................
Jam :
Tanggal :
Tanda tangan bidan
RM 006 b 3 / RI / RSD