FORMAT PENGKAJIAN

Tgl/Jam MRS : .................................................................................

Ruang : .................................................................................
No. Register : .................................................................................
Dx Medis : .................................................................................
Tgl Pengajian : .................................................................................

IDENTITAS KLIEN
Nama : ........................................................ Suami/Istri/Orangtua :
Umur : ........................................................ Nama : ........................................
Jenis kelamin : ........................................................ Pekerjaan : ........................................
Agama : ........................................................ Alamat : ........................................
Suku Bangsa : ........................................................
Bahasa : ........................................................ Penanggungjawab:
Pendidikan : ........................................................ Nama : ........................................
Pekerjaan : ........................................................ Alamat : ........................................
Status : ........................................................
Alamat : ........................................................

KELUHAN UTAMA
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RIWAYAT PENYAKIT SEKARANG

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Upaya yang telah dilakukan:

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Terapi yang telah diberikan :

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RIWAYAT KESEHATAN DAHULU

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RIWAYAT KESEHATAN KELUARGA
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GENOGRAM:

KEADAAN LINGKUNGAN YANG MEMPENGARUHI TIMBULNYA PENYAKIT

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POLA FUNGSI KESEHATAN

1. Pola persepsi dan tata laksana kesehatan
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2. Pola nutrisi dan metabolisme

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3. Pola eliminasi
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4. Pola aktivitas
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5. Pola istirahat-tidur
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6. Pola kognitif dan persepsi sensori

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7. Pola konsep diri

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8. Pola hubungan-peran
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9. Pola fungsi seksual-seksualitas

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10. Pola mekanisme koping

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11. Pola nilai dan kepercayaan

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PEMERIKSAAN FISIK
1. Status Kesehatan Umum
Keadaan/penampilan umum:
Kesadaran : ................................................................ GCS : ............................
BB sebelum sakit: ................................................................ TB : ............................
BB saat ini : ................................................................
BB ideal : ................................................................
Perkembangan BB: ................................................................
Status Gizi : ................................................................
 Status Hidrasi : ................................................................
Tanda-Tanda Vital :
TD : ..................... mmHg Suhu : ................................ᵒC
N : ...................... x/menit RR : ................................ x/menit

2. Kepala
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3. Leher
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4. Thoraks (dada)
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5. Abdomen
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6. Punggung
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7. Ekstremitas
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8. Genitalia dan anus

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9. Pemeriksaan neurologis
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PEMERIKSAAN DIAGNOSTIK
1. Laboratorium
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2. Radiologi
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TERAPI
1. Oral
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2. Parenteral
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3. Lain-lain
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......................, ................
Mahasiswa,

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NIM : .............................
7. Data Fokus
Data Subyektif Data Obyektif
 8. Analisa Data
No. Data Fokus Masalah Etiologi
A. DIAGNOSA KEPERAWATAN (Sesuai Prioritas)
No Diagnosa Keperawatan (P&E) Tanggal Ditemukan Tanggal Teratasi Nama Jelas
 PERENCANAAN KEPERAWATAN
(Meliputi tindakan keperawatan independen dan interdependen)

Tgl No Diagnosa Tujuan dan Rencana Tindakan Rasional Paraf &

Keperawatan (PES) Kriteria Hasil Nama
B. PELAKSANAAN KEPERAWATAN ( CATATAN KEPERAWATAN )
Tgl/Waktu No. Dx Kep Tindakan Keperawatan dan Hasil Paraf dan Nama Jelas
C. E V A L U A S I ( CATATAN PERKEMBANGAN )
No. Dx Kep Hari/Tgl/Jam Evaluasi Hasil (SOAP) (Mengacu pada tujuan) Paraf dan Nama Jelas