Nama mahasiswa : ....................................

Ruagan
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Tgl /jam pengkajian : .................................... No. RM
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RESUME
A. Identitas
Nama :
Umur :
Alamat :
Pekerjaan :
Agama :
Suku bangsa :
Tgl kunjungan :
1. Alasan kunjungan saat ini
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2. Keluhan Utama
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3. Riwayat Kesehatan Sekarang
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4. Riwayat penyakit dahulu
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5. Riwayat Keluarga (Penyakit Genetik, Penyakit Kronis, Gameli)
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6. Imunisasi (TT)
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B. Kebutuhan Dasar
a. Asupan nutrisi :
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 b. Eliminasi
1. Kesulitan BAK :
2. Kesulitan BAB :
c. Aktifitas dan latihan
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d. Pola tidur :
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e. Seksualitas
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f. Keadaan mental :
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g. Persepsi dan konsep diri
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C. Pemeriksaan Fisik
a. Keadaan umum :
b. Kesadaran :
c. Tanda-tanda vital :
TD : mmHg BB : kg
N : x/mnt TB : cm
RR : x/mnt
S : °c

d. Kepala :
e. Mata :
f. Mulut :
g. Hidung :
h. Telinga :
i. Leher :
j. Payudara :
k. Abdomen :

D. Pemeriksaan Penunjang
VOD :
VOS :
TIO :
E. Lain-lain

F. Terapi