Nama Pasien : ................................................ Hari/Tanggal : ............................................
No. MR : .............................................. Nama Perawat :............................................. Diagnosis Medis : ................................................ NIM : ............................................ A. HASIL PENGKAJIAN Seorang (bayi/anak laki-laki/anak perempuan)* berusia….........(hari/bulan/tahun)*, dirawat di RS/dibawa ibu ke Puskesmas* dengan keluhan……........................................................... Keluhan lain yang menyertai adalah......................................................................................... Pada pemeriksaan fisik (diperoleh/ditemukan/didapatkan) keadaan umum........................... Pemeriksaan tanda vital diperoleh TD.........mmHg, denyut nadi ....... x/menit, frekuensi napas …..........x/menit dan suhu …....... 0C. Pada pemeriksaan fisik (diperoleh/ditemukan/didapatkan)* (data fokus)................................ ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... Pada pemeriksaan laboratorium (darah/urine/feses/cairan serebro spinal)* diperoleh ................................................................................................................................................... ................................................................................................................................................... Pada pemeriksaan foto rontgen diperoleh gambaran……….................................................... ...................................................................................................................................................