I. Data umum
1. Kepala Keluarga (KK) : ................................................................
2. Alamat dan telepon : ................................................................
3. Pekerjaan KK : ................................................................
4. Pendidikan KK : ................................................................
5. Komposisi keluarga :.................................................................
1 2 3 4 1 2 3 1 2 3
1.
2.
3.
4.
Genogram:
6. Tipe keluarga : ................................................................
7. Suku bangsa : ................................................................
8. Agama : ................................................................
9. Status sosial ekonomi keluarga
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
10. Aktivitas rekreasi keluarga
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
II. Riwayat dan tahap perkembangan keluarga
11. Tahap perkembangan keluarga saat ini :
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
12. Tugas perkembangan keluarga yang belum terpenuhi
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
13. Riwayat kesehatan keluarga inti
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
14. Riwayat kesehatan keluarga sebelumnya
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
V. Fungsi keluarga
24. Fungsi ekonomi
..........................................................................................................................
..........................................................................................................................
25. Fungsi mendapatkan status sosial
..........................................................................................................................
..........................................................................................................................
26. Fungsi pendidikan
..........................................................................................................................
..........................................................................................................................
27. Fungsi sosialisasi
..........................................................................................................................
..........................................................................................................................
28. Fungsi pemenuhan (perawatan/pemeliharaan) kesehatan
a. Mengenal masalah kesehatan
..........................................................................................................................
..........................................................................................................................
b. Mengambil keputusan mengenai tindakan kesehatan
..........................................................................................................................
..........................................................................................................................
c. Kemampuan merawat anggota keluarga yang sakit
..........................................................................................................................
..........................................................................................................................
d. Kemampuan keluarga memelihara/memodifikasi lingkungan rumah
yang sehat
..........................................................................................................................
..........................................................................................................................
e. Kemampuan menggunakan fasilitas pelayanan kesehatan
..........................................................................................................................
..........................................................................................................................
29. Fungsi religius
..........................................................................................................................
..........................................................................................................................
30. Fungsi rekreasi
..........................................................................................................................
..........................................................................................................................
31. Fungsi reproduksi
..........................................................................................................................
..........................................................................................................................
32. Fungsi afeksi
..........................................................................................................................
..........................................................................................................................
1. Subjektif:
Objektif:
2. Subjektif:
Objektif:
3. Subjektif:
Objektif:
1.
2.
3.
No.
Diag
Kriteria Skor Pembenaran
.
Kep.
Total skor
2.
3.
1.
2.
3.
D. IMPLEMENTASI
No.
Diag.
Tanggal &
waktu Kep. Implementasi
1.
2.
E. EVALUASI
No.
Diag.
Tanggal &
waktu Kep. Evaluasi
1. S:
O:
A:
P:
2. S:
O:
A:
P:
Catatan:
Pada setiap tahap perlu dituliskan dengan jelas dan benar tentang tempat, tanggal,
nama perawat sebagai bukti identifikasi.