I.

FORMAT PENGKAJIAN

Nama Fasilitator : Nama Mhs :

Nilai : NIM :
Tgl. MRS : Jam :
No. Register : Tempat/ tgl pengkajian :
Diagnose Medis :

1. DATA SUBYEKTIF
1.1. Biodata
1.1.1 Identitas Klien
1) Nama pasien : ......................................................................................................
2) Umur : .....................................................................................................
3) Suku/ Bangsa : .....................................................................................................
4) Agama : .....................................................................................................
5) Pendidikan : .....................................................................................................
6) Pekerjaan : .....................................................................................................
7) Alamat : .....................................................................................................
8) Status perkawinan : .....................................................................................................

1.1.2 Penanggung Jawab Klien

1) Nama pasien :....................................................................................................
2) Umur :....................................................................................................
3) Suku/ Bangsa :....................................................................................................
4) Agama :....................................................................................................
5) Pendidikan :....................................................................................................
6) Pekerjaan :....................................................................................................
7) Hubungan dg klien :....................................................................................................
8) Alamat : :....................................................................................................

1.2. Keluhan utama/alasan kunjungan :

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1.3. Riwayat Keluhan/Penyakit Saat ini :
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1.4. Riwayat Penyakit Lalu :
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1.5. Riwayat Penyakit Keluarga :
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1.6. Pola Kebiasaan/Kebutuhan Sehari-Hari
1) Pola nutrisi:
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2) Pola eliminasi:
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3) Personal hygiene:
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4) Istirahat tidur:
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5) Pola aktifitas dan latihan:
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6) Pola kebiasaan yang mempengaruhi kesehatan:
1) Merokok : ..........................................................................................................
2) Jamu : ..........................................................................................................
3) Obat : ..........................................................................................................
4) Minuman keras : ..........................................................................................................
2. DATA OBYEKTIF
2.1 Antropometri :
1) Tinggi badan : ......................................................................................................
2) Berat badan : ......................................................................................................
3) Lingkar Lengan : ......................................................................................................
2.2 Tanda vital
1) Kesadaran: : ...........................................................................................................
2) Tekanan darah : .........................................................................................................
 3) Respirasi : .........................................................................................................
4) Suhu : .........................................................................................................
5) Nadi : .........................................................................................................
2.3 Pemeriksaan secara umum:
1) Kepala :
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2) Muka:
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3) Mata:
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4) Hidung:
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5) Mulut dan Tenggorokan :
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6) Dada dan Axilla:
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7) Mammae :
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8) Abdomen:
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9) Genitalia :
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10) Ekstremitas:
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TUGAS KDM 4
…………………………………………..silahkan isi samapai disini ………………………..

3. PEMERIKSAAN LABORATOTIUM/ RADIOLOGI

3.1 Pemerikaan Laboratorium :
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3.1 Pemeriksaan Radiologi :

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CATATAN TINDAKAN YANG DILAKUKAN
HARI / TANGGAL/ TINDAKAN YANG DILAKUKAN CI
JAM (PEMBIMBING)
 Mengetahui
C I / Ka.Ruangan Pemeriksa/Mahasiswa

(..................................................) (..................................................)

CATATAN TINDAKAN YANG DILAKUKAN

HARI / TANGGAL/ TINDAKAN YANG DILAKUKAN CI
JAM (PEMBIMBING)
 Mengetahui
C I / Ka.Ruangan Pemeriksa/Mahasiswa

(..................................................) (..................................................)

CATATAN KEGIATAN HARIAN

HARI / TANGGAL/ TINDAKAN YANG DILAKUKAN CI
JAM (PEMBIMBING)