Tangga MRS :

Jam Masuk :
Tangga Pengkajian :
No. RM :
Jam Pengkajian :
Diagnsa Masuk :

IDENTITAS
1. Nama Pasien :
2. Umur :
3. Alamat :

RIWAYAT PENYAKIT SEKARANG

1. Keluhan utama/ Masalah utama : ......................................................................
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2. Riwayat penyakit sekarang : ......................................................................
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RIWAYAT PENYAKIT DAHULU

1. Pernah dirawat? Ya Tidak
Kapan: .................................., Diagnosa: .....................................................
2. Riwayat penyakit kronik dan menular? Ya Tidak
 Jenis: ..............................................................................................................
Riwayat Kontrol: ...........................................................................................
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Riwayat penggunaan obat: ............................................................................
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3. Riwayat alergi? Ya Tidak
Jenis: ..............................................................................................................
4. Riwayat Operasi? Ya Tidak
Kapan: ...........................................................................................................

RIWAYAT PENYAKIT KELUARGA

Ya Tidak
Jenis ...........................................................................................................................
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OBSERVASI DAN PEMERIKSAAN FISIK

1. Tanda-tanda Vital
S: N: TD: RR:
Kesadaran: Compos Mentis Apatis Somnolen
Sopor Koma
2. Sistem Pernapasan ( Breathing )
Obstruksi : Tidak Sebagian Total
Benda asing : Tidak Padat Cair
Berupa : ..............................................................................................
a. Keluhan : Sesak Nyeri waktu napas
Batuk : Produktif Tidak produktif
Sekret : .........................................., Konsistensi: .......................................
 Warna : ..........................................., Bau: ...................................................
b. Irama Napas : Teratur Tidak teratur
c. Jenis : Dispneu Kusmaul Cheyne Stokes
d. Suara Napas : Vesikuler Bronkho vesikuler
Ronkhi Wheezing
e. Alat bantu napas : Ya Tidak
Jenis: ....................................., Flow.....................lpm