RM 14 b

Nama Pasien : ...................................... No. RM :

Jenis Kelamin: L / P Tgl Lahir : ........................../....... Thn

/ Bln / Hr

PENGKAJIAN
Ruang / Kelas ULANG PASIENTgl
: ...................................... RAWAT INAP
Masuk : ..................................

Petunjuk : Jam Pengkajian : .....................

Jam : ................. ..........................................................................................................................
Beri tanda ( ) pada kolom yang sesuai
1. Tiba di ruangan :............................
Tanggal : ............................................................. Pukul : .......................................................
2. Pengkajian : Tanggal : ............................................................. Pukul : .......................................................
Diperoleh dari : ..................................................................................................(nama jelas)
Hubungan dengan pasien : .....................................................................................................
3. Awal Masuk
Rumah Sakit : Bangsal Perawatan : ....................... Intensif : .............. Semi Intensif : .................
4. Konsulen : ..................................... Mulai tanggal : .................................. s/d .........................................
..................................... Mulai tanggal : .................................. s/d .........................................
..................................... Mulai tanggal : .................................. s/d .........................................
..................................... Mulai tanggal : .................................. s/d .........................................
..................................... Mulai tanggal : .................................. s/d .........................................
..................................... Mulai tanggal : .................................. s/d .........................................
5. Status Pembayaran :
(Sebelumnya) Pribadi Dijamin oleh : Perusahaan Asuransi
(Saat ini) Pribadi Dijamin oleh : Perusahaan Asuransi
PENGKAJIAN MEDIS (Diisi oleh Dokter) Jam : ...................

KONDISI SAAT INI

1. Keluhan : .................................................................................................................................................
.................................................................................................................................................
..........................................................................................................................................
.......
.................................................................................................................................................
2. Ringkasan Perawatan / Riwayat Pengkajian Sekarang (termasuk pemeriksaan, tindakan, pengobatan yang
berhubungan) :
Laboratorium : .................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
Radiologi : .................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
Penunjang Medis : .................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
Tindakan Medis : .................................................................................................................................................
.................................................................................................................................................
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PEMERIKSAAN UMUM

1. Keadaan Umum : Tampak tidak sakit Tampak sakit ringan

Tampak sakit sedang Tampak sakit berat
2. Kesadaran : Komposmentis Apatis Somnolen Sopor Koma
3. GCS : E : .................................... M : ................................. V: ......................................
PEMERIKSAAN FISIK

1. Pemeriksaan Fisik
a. Kepala : ...........................................................................................................................
....
b. Mata : ...............................................................................................................................
c. THT : ...............................................................................................................................
d. Leher : ...............................................................................................................................
e. Mulut : ...............................................................................................................................
 Thorax, Paru-paru dan payudara : ........................................................................................................................
Abdomen : ........................................................................................................................
Kulit dan Sistem Limfatik : ........................................................................................................................
Tulang belakang dan Anggota tubuh : ..........................................................................................................................
Sistem saraf : ........................................................................................................................
Genitalia, Anus dan Rektum : ........................................................................................................................
Lain-lain : ........................................................................................................................
Status Lokalis : ........................................................................................................................
Diagnosa Medis
Masuk : .............................................................................................................................................................
Saat ini : .............................................................................................................................................................

Diisi oleh Dokter yang Melakukan Pemeriksaan Tanda Tangan Dokter

Tanggal :

Waktu selesai pukul : Nama :

Diisi oleh DPJP

Perencanaan Pelayanan :

Dokter (DPJP)

(............................................)
Tanda Tangan & Nama Terang

Diisi oleh Perawat

Tanda Vital : Tekanan darah : ........................... mmHg Nadi : ................... x/ml

Pernafasan : ........................... x/mt Suhu : ................... oC
Luka (kondisi terakhir luka operasi, luka decubitus dll)
.............................................................................................................................................................................................
.............................................................................................................................................................................................
Masalah Keperawatan saat ini :
Nyeri Keselamatan Pasien Tumbuh Kembang
Pola Tidur Nutrisi Suhu Tubuh
Mobilitas / Aktivitas Eliminasi Perfusi Jaringan
Integritas Kulit Pengetahuan / Komunikasi Konflik Peran
Perawatan Diri Keseimbangan Cairan dan Elektrolit Jalan nafas / Pertukaran Gas
Lain-lain
Rencana Tindakan yang belum dilakukan dan alasan :
.............................................................................................................................................................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................

Diisi oleh Perawat yang Melakukan Pemeriksaan Nama dan Tanda Tangan Perawat

Tanggal :

Waktu selesai pukul :

(.................................................)