DOKUMENTASI KEPERAWATAN

NAMA : Ahmad Mustofa Kamal

NIM : PO71201210074

POLITEKNIK KESEHATAN KEMENTERIAN KESEHATAN JAMBI

PRODI DIV ALIH JENJANG JURUSAN KEPERAWATAN
TAHUN AJARAN 2021/2022
 KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
POLITEKNIK KESEHATAN JAMBI
JURUSAN KEPERAWATAN
JL. Dr. Tazar No.05 Buluran Kenali Telanaipura Jambi Telp (0741)65816

FORMAT PENGKAJIAN KEPERAWATAN

Tanggal/ jam masuk RS : .......................................................

Ruang : ........................................................
No. Register : .......................................................
Diagnosa Medis : .......................................................
Tanggal Pengkajian : .......................................................

IDENTITAS KLIEN
Nama : ............................................ Suami/Isteri/Ortu :
Umur : ............................................ Nama : ..................................
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Jenis Kelamin : ............................................ Pekerjaan : ..................................
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Agama : ............................................ Alamat : ..................................
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Suku/ bangsa : ............................................ ..................................
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Bahasa : ............................................ Penanggung : ..................................
Jawab ....
Pendidikan : ............................................ Nama : ..................................
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Pekerjaan : ............................................ Alamat : ..................................
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Status : ............................................ ..................................
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Alamat : ............................................
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KELUHAN UTAMA
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RIWAYAT PENYAKIT SEKARANG

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Upaya yang telah
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Terapi yang telah
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RIWAYAT KESEHATAN DAHULU

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RIWAYAT KESEHATAN KELUARGA

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Genogram :

KEADAAN LINGKUNGAN YANG MEMPENGARUHI TIMBULNYA PENYAKIT

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POLA FUNGSI KESEHATAN

1. Pola persepsi dan tata laksana kesehatan
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2. Pola nutrisi dan metabolisme

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3. Pola eliminasi
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4. Pola aktivitas
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5. Pola istirahat tidur

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6. Pola kognitif dan persepsi sensori

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7. Pola konsep diri

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8. Pola hubungan peran

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9. Pola fungsi seksual-seksualitas

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10. Pola mekanisme koping

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11. Pola nilai dan kepercayaan

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PEMERIKSAAN FISIK
1. Status kesehatan umum
Keadaan/ penampilan umum :
Kesadaran : ................................................. GCS : ....................................
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BB sebelum sakit : ................................................. TB : ....................................
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BB saat ini : .................................................
BB ideal : .................................................
Perkembangan BB : .................................................
Status gizi : .................................................
Status Hidrasi : .................................................

Tanda-tanda vital :
TD : ............... mmHg Suhu : .................. 0C
N : ............... x/mnt RR : .................. x/mnt

2. Kepala
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3. Leher
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4. Thorak (dada)
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5. Abdomen
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6. Tulang belakang
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7. Ekstremitas
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8. Genitalia dan anus

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9. Pemriksaan neurologis
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PEMERIKSAAN DIAGNOSTIK
1. Laboratorium
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2. Radiologi
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3. Lain-lain
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TERAPI
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2. Parenteral
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3. Lain-lain
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Jambi, .......................................
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Mahasiswa
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NIM. .........................................
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NO ANALISA DATA PENYEBAB MASALAH

ANALISA DATA
 DIAGNOSA KEPERAWATAN
N TGL/JAM DIAGNOSA KEPERAWATAN PARAF
O
TGL/JAM DIAGNOSA NOC NIC PARAF
KEPERAWATAN

INTERVENSI KEPERAWATAN
 PELAKSANAAN TINDAKAN KEPERAWATAN
NO. TGL/JAM TINDAKAN KEPERAWATAN PARAF
DX
 EVALUASI KEPERAWATAN
MASALAH TGL/ CATATAN PERKEMBANGAN PARAF
KEPERAWATAN JAM
A. Pendapat Perbandingan

Menurut perbandingan saya model dokumentasi diatas sama dengan model

pendokumentasian POR (problem oriented record). Dimana data dasarnya adalah
kumpulan informasi pasien yang telah dikaji sejak pertama kali pasien masuk rumah
sakit, dan data dasarnya meliputi riwayat keadaan pasien, riwayat keluarga pasien,
keadaan penyakit yang dialami pasien tindakan yang pernah diberikan, pemeriksaan
fisikdan pemeriksaan penunjang pasien. Dan daftar masalahnya merupakan hasil
penafsiran dari data dasarnya. dimana daftar masalah ini mencerminkan keadaan yang
tidak normal pada pasien, dari data inilah kita dapa tmengetahui diagnosis yang akan di
angkat untuk mengatasi masalah prioritas, sehingga kita dapat menentukan intervensi
yang akan di berikan dengan model pendokumentasian ini juga dapat melihat
perkembangan keadaan pasien yang didasarkan pada masalah pasien sendiri sehingga
kita juga dapat melihat intervensi yang kita berikan apakah sudah efektif atau belum.