1. Judul :
2. Identitas pasien :
A. Biodata Pasien :
1) Nama Pasien : ........................................................................................
2) Jenis Kelamin : ........................................................................................
3) Status Perkawinan : ........................................................................................
4) Agama : ........................................................................................
5) Pendidikan Terakhir : ........................................................................................
6) Pekerjaan : ........................................................................................
7) Suku : ........................................................................................
8) Alamat : ........................................................................................
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9) Tanggal masuk RS : ........................................................................................
10) Tanggal Pengkajian : ........................................................................................
11) Dx . Medis : ........................................................................................
12) No. Register : ........................................................................................
B. PENGKAJIAN PRIMER
Airways
Breathing
Circulation
Disibility
Explosure
2. 7.
3. 8.
4. 9.
5. 10.