AKADEMI KEPERAWATAN DIAN HUSADA MOJOKERTO

Data diambil tanggal : …………………………… Jam: ……….

Ruang rawat / kelas : ……………………………
No. Rekam Medik : ……………………………

FORMAT PENGKAJIAN KEPERAWATAN ANAK

I. IDENTITAS ANAK IDENTITAS ORANG TUA

Nama : ...................... Nama Ayah : ......................
Tanggal Lahir : ...................... Nama Ibu : ......................
Jenis Kelamin : ...................... Pekerjaan Ayah/Ibu : ......................
Tanggal MRS : ...................... Pendidikan Ayah/Ibu : ......................
Diagnosa Medis : ...................... Agama : ......................
Sumber Informasi: ...................... Suku/Bangsa : ......................
Alamat : ..............................................................................................
.............................................................................................................................

II. RIWAYAT KEPERAWATAN

1. Keluhan Utama : ..............................................................................................
..............................................................................................................................
..............................................................................................................................
2. Riwayat Keperawatan Sekarang : ......................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
3. Riwayat Keperawatan Sebelumnya :
1) Riwayat Keperawatan yang lalu :
(1) Penyakit yang pernah diderita :
Demam Kejang Batuk/pilek
Mimisan Lain-lain : …………………………………………..
(2) Operasi :
Ya Tidak Tahun : ……………………………………..
(3) Alergi :
Makanan Obat Udara
Lainnya sebutkan : …………………………………………………………….