PROGRAM D3 KEPERAWATAN

FAKULTAS ILMU KEGURUAN DAN PENDIDIKAN

UNIVERSITAS SULTAN AGENG TIRTAYASA
KERANGKA ACUAN PRAKTEK KEPERAWATAN KELUARGA
MAHASISWA TINGKAT III SEMESTER V
TAHUN AKADEMIK 2018/2019

FORMAT PENGKAJIAN KEPERAWATAN KELUARGA

I. Data Umum
1. Nama KK : ......................................................................................
2. Alamat dan telfon : ......................................................................................
3. Pekerjaan KK :
4. Pendidikan KK :
5. Tanggal Pengkajian :
6. Komposisi Anggota Keluarga

Jenis
No Nama Hubungan Keluarga Usia Pendidikan Ket
Kelaamin
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Genogram

Keterangan:
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.................................................................................................................................. .......................................
.........................................................................................................................................................................

7. Tipe Keluarga
..................................................................................................................................................................
..................................................................................................................................................................
..................................................................................................................................................................
..................................................................................................................................................................
..................................................................................................................................................................
..................................................................................................................................................................
..................................................................................................................................................................