FORMAT PENGKAJIAN IPE -IPC

NAMA KK :

ALAMAT LENGKAP :

A. IDENTITAS PASIEN
NAMA :

NAMA ORTU :

UMUR :

JENIS KELAMIN :

PEKERJAAN :

PENDIDIKAN :

B. KELUHAN UTAMA/KONDISI SAAT INI :

..................................................................................................................................................
..................................................................................................................................................
KHUSUS IBU HAMIL (G.......P.........A.........)

C. RIWAYAT PENYAKIT LALU /KETURUNAN (PTM)

..................................................................................................................................................
.................................................................................................................................................

D. RIWAYAT PERTUMBUHAN DAN PERKEMBANGAN (KMS BILA PASIEN ANAK)) :

..................................................................................................................................................
.................................................................................................................................................

E. RIWAYAT IMUNISASI : (PASIEN ANAK ATAU IBU HAMIL)

..................................................................................................................................................
................................................................................................................................................
F. POLA PEMENUHAN NUTRISI :
..................................................................................................................................................
.................................................................................................................................................

FORM IPE-IPC POLTEKKES KEMENKES BANTEN 2021

G. POLA PEMENUHAN ELIMASI :
..................................................................................................................................................
.................................................................................................................................................

H. POLA PEMENUHAN KEBUTUHAN ISTERAHAT :

..................................................................................................................................................
.................................................................................................................................................

I. PERSONAL HYGIENE :
..................................................................................................................................................
.................................................................................................................................................

J. PEMERIKSAAN KESEHATAN (CEK UP KESEHATAN )YANG PERNAH DILAKUKAN

..................................................................................................................................................
..................................................................................................................................................
KHUSUS IBU HAMIL ; ANC 1.2.3.4

K. PEMERIKSAAN FISIK :

BB ............., TB ............, TD ..............., Suhu ............., Nadi ..............., RR...............

L DATA PENUNJANG ;
INSPEKSI ;

PALPASI :

AUSKULTASI :

PEMERIKSAAN LABRATORIUM :..........................................................................................................

M. OBAT-OBATAN YANG DIDAPAT

..............................................................................................................................................................................

..............................................................................................................................................................................

N. DATA LINGKUNGAN YG MENUNJANG (PENY. MENULAR/TDK MENULAR)

..............................................................................................................................................................................

..............................................................................................................................................................................

O. DATA TAMBAHAN LAIN YANG DIPERLUKAN

....................................................................................................................................................................................

....................................................................................................................................................................................
FORM IPE-IPC POLTEKKES KEMENKES BANTEN 2021
 ....................................................................................................................................................................................

...................................................................................................................................................................................

FORM IPE-IPC POLTEKKES KEMENKES BANTEN 2021

FORMAT 2
FORMAT TINDAK LANJUT
 MASALAH TINDAKAN RTL

MENGETAHUI SERANG, 2018

PEMBIMBING
TIM IPE-IPC JURUSAN
TANDA TANGAN
1..............................
1....................................... 2..............................
2....................................... 3.............................
4.............................