ASSESSMENT FORM

Of CHRONIC RENAL FAILURE (CRF)

Disusun Untuk Memenuhi Tugas Praktik Laboratorium Bahasa Inggris V

Dosen Pembimbing : Bapak Handoyo, MN.

Disusun Oleh :

Dwinda Maulina Rahma

P1337420218033

Tingkat 3A

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN KEMETERIAN KESEHATAN SEMARANG

JURUSAN KEPERAWATAN

PROGRAM STUDI DIII KEPERAWATAN PURWOKERTO

2020
 Assessment Form Cronic Renal Failure (CRF)

PERSONAL DETAILS

Name :
Preferred Name :
MRN :

Date of Admission :
Admitted From :

Gender : M F

Permanent admission - Room No.

Respite admission - Date of discarge / /

Last Fixed Addres :

Marital Status : M W S D Spous/Partner :

Date of Birth : Madicare No.

Expiry Date :

Country of Birth :
Pension No.
DVA No. Colour :

Religion : Attend church Chapalin visits

Language Spoken :
Interpreter Required : No Yes

Private Health Insurance : No Yes

Health Fund Name & No :

Electoral Roll Status : Active Inactive

Emergency Contacts / Person Responsible

Name :
Relationship :
Addres :
 Ph : (H) (W)

Financial Management

Self Other - Name : Relationship :

Address :
Ph : (H) (W)

DX :

Past History :

Allergies :

Nursing Assesment

V/S : Time : …………….

B/P ……… HR ……… RR ……… T ……… O2 ……… O2 sat : ……… Pain ………
EF% ……

GI & RENAL

NPO since Date/Time : Mucous Membranes :

Moist Y/N

Diet : Oral : …………. TPN Enternal Gastric Postpylonic

Anorexia Nausea Emesis

Descibe : ……………………………

Abdomen :

Bowel Sounds :

Normal Hypoactive Hyperactive Absent

Catheter : Foley Suprapubic Condom Peritoneal A/V Fistula Close

drainage

Urin :
Weight : kg Height : cm