RUMAH SAKIT IBU DAN ANAK No.

RM :
BUNDA ASY-SYIFA Nama :
Alamat : Jl. Dr. Susilo No. 54 Pahoman Teluk Betung Utara
Bandar Lampung Tanggal Lahir :
Telp : 0721 256256 / 0721 259259
Website : www.rsiabundaasy-syifa.com Jenis Kelamin :
e-mail : bunda.asysyifa@yahoo.com / rsia.bunda.asy.syifa@gmail.com

ASSESMENT AWAL POLIKLINIK ANAK

Pemeriksaan Tanggal : ............/........../............... Jam : ......................... Wib
Nama Perawat : Tandatangan :

1. Asesmen Perawat
a. Data Subyektif :
Ananmnese : ............................................................................................................................................................................
Riwayat Penyakit : ...................................................................................................................................................................
b. Data Obyektif :
Keadaan Umum : Baik Sedang Buruk BB : ............. kg TB : ............Cm
Keadaan Gizi : Baik Cukup Kurang
Tensi : ………/……… mm.Hg Nadi : ……………….x/mnt Suhu : ………..…. C° Nafas : ………….. x/mnt
c. Asesmen Nyeri :
P : Pencetus : ……………….
Q : qualitas/ quantitas: Bersifat:  Tumpul  Panas Seperti Terbakar  Berdenyut  Menusuk
Frekuensi:  Hilang Timbul  Terus Menerus  Lama Nyeri : ……….
R : Lokasi : ………………….. S : Skala Nyeri : …………… T : Timing :  Mendadak  Bertahap
Kesadaran / GCS : .....................................................................................................................................................................
2. Asesmen dokter
a. Data Subyektif :
Keluhan utama : ……………………………………………………………………………………………………………........
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Riwayat penyakit sekarang : ……………………………………………………………………………………………………
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Riwayat imunisasi : ……………………………………………………………………………………………………………...
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b. Data Objektif
Kondisi Umum : ………………………………………………………………………................…………………………….
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Kepala Leher : …………………………………………………………………………………………………….……….….
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Thorax : ………………………………………………………………………................……………………………….
Abdomen : ………………………………………………………………………...........………………………………….
Ekstermitas : ………………………………………………………………………...........………………………………….
Pemeriksaan Penunjang : ………………………………………………………………………...........…………………………
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c. Diagnosis : ………………………………………………………………………...........……………………………
Diagnosis Banding : ………………………………………………………………………...........……………………………
Rencana Tindakan : ………………………………………………………………………...........……………………………
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Terapi : ………………………………………………………………………...........……………………………………......
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d. Edukasi : ………………………………………………………………………...........…………………….………………......
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Bandar Lampung, ............/........../...............Jam : ………………. WIB
Nama DPJP : Tanda tangan :

*isilah ……… diatas dengan benar, berilah tanda ceklis (√) pada jawaban yang benar / sesuai.

RM 2.1 /RSIA-BA/2019