Format Ruang Poli
Format Ruang Poli
Format Ruang Poli
(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
( _______________________ ) ( ___________________ )