Nama :

NIM :
Ruangan :
STIKes Hafshawaty
Zainul Hasan Genggong Probolinggo

FORMAT ASUHAN KEPERAWATAN

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

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

I. IDENTITAS KLIEN
Nama :……………………………………………………………………..
Umur :…………………………………………………………………….
Jenis Kelamin :…………………………………………………………………….
Suku / Bangsa :……………………………………………………………………
AgamaPekerjaan :……………………………………………………………………
Pendidikan :……………………………………………………………………
Alamat :……………………………………………………………………
No. Register :…………………………………………………………………….
Tanggal MRS :………………………………………………..............................
Diagnosa Medis :………………………………………………..............................
Sumber Informasi :………………………………………………..............................
Penanggung : Askes / Astek / Jamsostek / JPS / Sendiri

II. KELUHAN UTAMA

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III. RIWAYAT PENYAKIT SEKARANG
Alasan Masuk rumah sakit
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 Upaya yang telah dilakukan :
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 Terapi / operasi yang dilakukan :
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IV. RIWAYAT KESEHATAN / PENYAKIT DAHULU
 Penyakit yang pernah diderita .
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....
 Obat-obatan yang biasa dikonsumsi
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 Kebiasaan berobat ..
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 Alergi
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 Kebiasaan merokok / alcohol
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V. RIWAYAT KESEHATAN / PENYAKIT KELUARGA
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 Genogram :

VI. PEMERIKSAAN FISIK

B1 (BREATING)
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B2 (BLOOD)
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B3 (BRAIN)
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B4 (BLADDER)
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B5 (BOWEL)
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B6 (BONE)
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