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Kcueng Aand
AYY CBA L
Pengkajian dilakukan pada har
CONTOH FORMAT LAPORAN KASUS
BO0(S
ECAICRUT Tota EWOUKa DexeTO
a
U
0030 |
tanggal jam.
dengan menggunakan
metode alloanamnesa dan autoanamnesa, Pemeriksaan fisik dan melihat status klien.
A. Biodata
dentitas klien
Nama
Umur
Agama
Pendidikan
Pekerjaan
Jenis kelamin
‘Status perkawinan
Alamat
‘Sumber informasi
|. Penanggung jawab
Nama
mur
Jenis kelamin
Alamat
Status
Hubungan
STL
PT Be
\s- 6- OS
tectsken
+ secotan dasar
PSuAStA/ Lan
# Lates- Layer,
remucan
1 Tawang,
Rasen dag -Cecasy toactte
PRO
2 6% TAWUA
+ PereMgyan
1 TAVANG,
F MANKaY
iskey Rasten
Dipindai dengan CamScanner 1M, Identitas medis
‘Tanggal/jam masuk + COMM, 2U PLAFEMMWwWeS BO /00.21
Bangsal/kamar TENQgang 2 / 208-3
‘Dx Medis FERCEUT 4K ELWUIA Bextra
No.Register/RM. OWA
B,_Riwayat penyakit
1, Keluhan Utama saat masuk RS»
Kanan
Keluhan saat utama saat pengkajian’: +
Wert. cad
~
3. Riwayat Penyakit Sekarang
fasteg, Aicawat ACTUMAW SOY
4, Riwayat Penyakit Dahulu +
Raatenitnenopracath Perna dicos
5. Riwayat Penyakit Keluarga dan genogram
PASTE), METADKAKAN RAGS, CetVOCQONYA
Caronug,
Pengkajian Saat ni
1. Persepsi dan Pemeliharaan Kesehatan
JEAN pMaEr
indai dengan CamScanner 2. Pola nutrisi /metabolic
{8B Klien saat pengkajia
IMT= BB (kgl/TB (cm)/100)?
+ Sebelum masuk RS +.
+ Selama dirawat
3. Pola eliminasi
> Sebelum masuk RS : LASKED Menger
Selama masuk RS-
4. Pola Aktivitas dan latihan
Kemampuan perawatan | 0 1
iri
Makan / minum
Mandi
ing
Berpakaian
Mobilisasi di tempat tidur
Berpindah,
“Ambulasi / ROM, .
Keterangan:
= manditt 3 =
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