Ruangan Rawat : …………………………….

Tanggal Dirawat : ……………………

I. Pengkajian
Hari/Tanggal pengkajian :
A. IDENTITAS
1. IDENTITAS KLIEN
Nama :
Jenis Kelamin :
Umur :
Pendidikan :
Pekerjaan :
Alamat :
Status Perkawinan :
Agama :
Suku/bangsa :
Tanggal masuk RS :
Diagnosa Medis :
Nomer Rekam Medik :

2. IDENTITAS PENANGGUNG JAWAB

Nama :
Jenis Kelamin :
Umur :
Pekerjaan :
Alamat :
Hubungan dengan klien :

B. RIWAYAT KESEHATAN
1. Keluhan Utama
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3. Riwayat Kesehatan/Penyakit Dahulu
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4. Riwayat Kesehatan/Penyakit Keluarga
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C. PEMERIKSAAN FISIK
1. Keadaan Umum
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2. Kulit
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3. Kepala dan Leher
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4. Penglihatan dan Mata
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5. Penciuman dan Hidung
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6. Pendengaran dan Telinga
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7. Mulut dan Gigi
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8. Dada, Pernafasan dan Sirkulasi

Inspeksi : ……………………………………………………………………………
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Palpasi : ……………………………………………………………………………
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Auskultasi : ………………………………………………………………………..
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Sirkulasi : …………………………………………………………………………..
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9. Abdomen
Inspeksi : ……………………………………………………………………………
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Auskultasi : ………………………………………………………………………….
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 Palpasi : ……………………………………………………………………………
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Perkusi : .…………………………………………………………………………
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10. Genetalia dan Reproduksi

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11. Ekstremitas Atas dan Bawah

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D. KEBUTUHAN FISIK, PSIKOLOGI, SOSIAL DAN SPIRITUAL
1. Aktivitas dan Istirahat (di rumah/sebelum sakit dan di rumah sakit/saat sakit)
Di rumah :
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Di RS :
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2. Personal Hygiene
Di rumah :
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 Di RS :
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3. Nutrisi
Di rumah :
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Di RS :
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4. Eliminasi (BAB dan BAK)

Di rumah :
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5. Seksualitas
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6. Psikososial
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7. Spiritual
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E. DATA FOKUS
1. Data Subjektif
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2. Data Objektif
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F. TERAPI FARMAKOLOGI
No Nama Dosis Cara Komposisi Golonga Indikasi/ Efek
Obat Pemberian Obat Kontraindikasi Samping
(Isi)
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II. ANALISA DATA
NO DATA MASALAH ETIOLOGI

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Prioritas Masalah :
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III. INTERVENSI (PERENCANAAN)
Hari/ No Diagnosa
Tanggal
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Planning
(NOC)
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Intervensi
(NIC)
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IV. IMPLEMENTASI
No Hari/ Pukul No Implementasi Evaluasi Paraf
Tangggal Dx
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V. EVALUASI
No Hari/ Pukul Evaluasi Paraf
Tanggal
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CATATAN PERKEMBANGAN
No Catatan Perkembangan Paraf

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