Nama Perawat:.........................

Tanggal pengkajian:................

I. PENGKAJIAN
1. Identitas Pasien
Nama :
Umur :
Jenis kelamin :
Agama :
BB :
No. Rekam Medik :
Diagnosa Medik :
2. Riwayat penyakit
Keluhan Utama
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Riwayat penyakit sekarang (pengkajian yang dilakukan saat awal ketemu pasien):
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Riwayat penyakit dahulu :
- Riwayat saat di IGD:
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 - Riwayat pengobatan:
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- Riwayat penyakit sebelumnya:

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- Lain-lain:
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Riwayat penyakit keluarga :

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3. Pengkajian Kritis B6
a. B1 (Breathing)
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b. B2 (Blood)
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 c. B3 (Brain)
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d. B4 (Bowel)
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e. B5 (Bladder)
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f. B6 (Bone)
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4. Pemeriksaan Fisik Head to Toe (narasikan sesuai dengan IPPA)

a. Kepala
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b. Mata
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c. Hidung
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d. Telinga
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e. Mulut
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f. Leher
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g. Dada
1) Jantung
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2) Paru
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h. Abdomen
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i. Ekstremitas
1) Atas
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2) Bawah
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j. Genetalia
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5. Data Penunjang
a. Pemeriksaan Laboratorium (abnormal)
Tanggal Pemeriksaan Hasil Nilai Satuan
Rujukan
 b. Pemeriksaan ST Scan (hasil gambarannya)
Tanggal..........
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c. Pemeriksaan Thoraks
Tanggal...........
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d. Pemeriksaan Lain-lain
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6. Terapi
No Tangg Nama Dosis N Tangg Nama therapi Dosis
al therapi o al

No Tangg Nama Dosis N Tangg Nama therapi Dosis

al therapi o al

7. Perjalanan Ventilator (jika pasien terasang ventilator)

No. Tanggal Settingan Ventilator
II. ANALISA DATA
No Tanggal Data Etiologi Masalah
III. DIAGNOSA KEPERAWATAN
IV. RENCANA KEPERAWATAN
No Diagnosa Tujuan Intervensi Rasional
Keperawatan
1.
V. IMPLEMENTASI KEPERAWATAN
Tanggal/Dx Implementasi Respon TTD
VI. EVALUASI
Tanggal Dx. Kep SOAP