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POLITEKNIK KESEHATAN SURAKARTA Lampiran

JURUSAN OKUPASI TERAPI

Kenny Self-Care Assessment Scale

Nama klien : Diagnosa medis :


Umur : Tanggal awitan :
Pekerjaan : Tanggal pemeriksaan OT :
Alamat : Okupasi terapis :

Penilaian :
0 ketergantungan penuh
1 bantuan sebagian besar
2 bantuan sedang
3 bantuan / supervisi minimal
4 mandiri

NO AKTIVITAS NILAI
1 Bed ..
Move in bed
Rise and sit

2 Transfer ..
Sitting
Standing
Toilet

3 Locomotion ..
Walking
Stairs
Wheelchair

4 Dressing ..
Upper trunk and arms
Lower trunk and arms
Feet

5 Personal hygiene ..
Face, hair, arms
Trunk, perineum
Lower extremities
Bowel programme
Bladder programme

6 Feeding ..

Kesimpulan : , ...

Okupasi Terapis

..

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