FORM DOKUMENTASI KEPERAWATAN

FALETEHAN HOSPITAL
Cilegon Street KM. 06, Pelamunan, Kramatwatu, Serang, Banten
Phone/Fax: 0254 232729/230054
Patient’s identity Immunization History
Name : Tn. Agus F Vaccine Yes No Not When
sure
Age : 22 Polio X
Address : labuan DPT X
Occupation : Indonesia Measles X
Phone number : 0837771312888 Rubella X
Vital signs checking
Temperature : 36,2 C Pulse rate : 90 x/minute
Blood pressure : 120/90 mmHg Respiration : 21 x/minute
Physical assessment results
Head : Face : Neck :
No Problem No Problem No Problem
Nose : Sinuses : Mouth :
No Problem No Problem No Problem
Pharynx : Eyes : Ears :
No Problem No Problem No Problem

Assessor : Saepullah
Day, date, time : Friday, 29 January 2022, 09:00