Di Rumah Sakit...............................................................................
Laporan kasus pada ..........dengan diagnosa medik ...............................................
Tanggal pengkajian : ………………….
Tanggal Operasi : ………………… Tempat Praktek : Ruangan OK RS………..
1. Post operasi care
............................................................................................................................................................ ............................................................................................................................................................ a. Identitas Nama pasien : ................ Jenis kelamin : ................ Usia : ................ Status perkwinan : ................ Agama : ................ Suku : ................ Pekerjaan : ................ Alamat : ................ Diagnosa medik : ................
2. Keluhan utama
............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ 3. Riwayat penyakit ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ 4. Pemeriksaan fisik Keadaan umum : ........... Tingkat kesadaran : ........... GCS : E ........... V ........... M ........... Nilai normal GCS : ........... Vital Sign : Tekanan darah : ........... Nadi : ........... Suhu : ........... Pernafasan : ...........