FORMULIR PENGKAJIAN

Nama RS : ………………….. Tanggal Pengkajian : ……………….

Alamat : …………………..
I. IDENTITAS KLIEN
Nama : .......................................................(L / P)
Tanggal masuk : ..................................................................
Umur : ..................................................................
No. Pendaftaran : ..................................................................
Alamat Rumah : ..................................................................
Agama : ..................................................................
Status Perkawinan : ..................................................................
Pendidikan Terakhir : ..................................................................
Pekerjaan : ..................................................................

II. ALASAN KUNJUNGAN KE RS / PUSKESMAS

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III. RIWAYAT KESEHATAN

Masalah kesehatan :
- Yang pernah dialami : ...........................................................
Yang dirasakan saat ini :

IV. KEBIASAAN SEHARI-HARI

A. Biologis
1. Pola makan : .........................................................................
2. Pola minum : .........................................................................
3. Pola tidur : .............................................................................
4. Pola eliminasi (BAB/BAK) : .................................................
5. Aktivitas sehari-hari : ............................................................
6. Rekreasi : ...............................................................................
 B. Psikologis
1. Keadaan emosi : .....................................................................
C. Sosial
1. Dukungan keluarga :...............................................................
2. Hubungan antar keluarga :......................................................
3. Hubungan dengan orang lain :................................................
D. Spiritual
1. Pelaksanaan ibadah : ..............................................................
2. Keyakinan tentang kesehatan :...............................................

V. PEMERIKSAAN FISIK
A. Tanda vital
 Keadaan umum : ...................................................................
 Kesadaran : ............................................................................
 Nadi : .............TD: ................................P:............................
 S : ....................TB: ...........................BB :............................

B. Kebersihan perorangan
1. Kepala
 Rambut : ........................................................................
 Mata : .........................................................................
 Hidung : .........................................................................
 Mulut : .........................................................................
 Telinga : .........................................................................
2. Leher : .........................................................................

C. Dada / Thorak
 Dada :
Inspeksi : .........................................................................
Palpasi : .........................................................................
Perkusi : .........................................................................
Auskultasi :.......................................................................
  Paru-paru :.........................................................................
 Jantung : .........................................................................
Inspeksi : .........................................................................
Palpasi : .........................................................................
Auskultai : .........................................................................

D. Abdomen : ..................................................................................
Inspeksi........................................................................................
Palpasi .........................................................................................
Perkusi.........................................................................................
Auskultasi....................................................................................

E. Muskuloskeletal :

VI. INFORMASI PENUNJANG

1. Diagnosa medis : .......................................................................
2. Laboratorium : ...........................................................................
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3. Terapi medis : ............................................................................

VII.DAFTAR MASALAH KEPERAWATAN

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……………………………., …………….
Mahasiswa

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 ANALISA DATA

No Data Fokus Masalah Etiologi

 RENCANA ASUHAN KEPERAWATAN

No Dx. Keperawatan Tujuan & Kriteria Hasil Rencana Tindakan

(NOC) (NIC)
 CATATAN PERKEMBANGAN TERINTEGRASI

No Hari / Diagnosa Jam Implementasi Jam Evaluasi Nama

Tgl &
TTD
 Activity Daily Living

Nama :
Tanggal :
Ruangan :

No Jam Aktivitas Nama pasien Ttd

perawat

Pekanbaru,
Preceptor Klinik Preceptor Akademik

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 FORMAT RESUME ASUHAN  KEPERAWATAN
…..., ……………..……. 2012

A.Identitas Pasien 
Nama   : No RM  :
Umur  :   Tgl MRS :
Jenis Kelamin :  Dx Medis :
Alamat  : 

B. Data Fokus

 S : (Data Subjektif Pasien)

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 O : (Data Objektif Pasien )

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 A : (Diagnosa Keperawatan Yang Muncul)

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 P : <Rencana Keperawatan Pada Hari Itu Diperlukan Untuk Mengatasi Diagnosa Pada
Point A>
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 I : (Implementasi Yang Dilakukan Pada Hari Itu>

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 E : <Evaluasi Hari Itu Untuk Masalah Pada Point A>

S: ……………………………………………………………………………
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O:
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A:
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P:
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Mengetahui Preceptor Klinik Dumai , ……………………….

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