Format Ruang Poli

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PENGKAJIAN DATA FOKUS

(RUANG POLI)
Pengkajian diambil tanggal : ................................... Jam : ............................................
Diagnosa Medis : .................................. No. Reg : .............................................

IDENTITAS PASIEN
1. Nama : ........................................................................................................
2. Umur : ........................................................................................................
3. Jenis Kelamin : ........................................................................................................
4. Agama : ........................................................................................................
5. Suku / Bangsa : ........................................................................................................
6. Bahasa : ........................................................................................................
7. Pendidikan : ........................................................................................................
8. Pekerjaan : ........................................................................................................
9. Alamat : ........................................................................................................
10. Alamat yang Mudah Dihubungi : ........................................................................................................
11. Ditanggung oleh : ASKES / ASTEK / JAMSOSTEK / JPS / SENDIRI

NO DX HARI /
CATATAN PERKEMBANGAN
KEPERAWATAN TANGGAL
NO DX HARI /
CATATAN PERKEMBANGAN
KEPERAWATAN TANGGAL
NO DX HARI /
CATATAN PERKEMBANGAN
KEPERAWATAN TANGGAL

Mengetahui
Pembimbing Ruangan Mahasiswa

( _______________________ ) ( ___________________ )

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