Beruflich Dokumente
Kultur Dokumente
MRS :
Ruangan :
Reg :
DX :
I. A. Identitas Klien
Nama :
Tempat/tgl lahir :
Jenis Kelamin :
Nama ayah/ibu :
Pekerjaan Ayah :
Pekerjaan Ibu :
Alamat :
Suku bangsa :
Agama :
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1. Prenatal
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2. Natal
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3. Postnatal
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5. Hospitalisasi/Tindakan (operasi)
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7. Alergi
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8. Kecelakaan
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9. Imunisasi
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10. Pengobatan
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V. Riwayat Pertumbuhan
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a. Sosial ekonomi
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b. Penyakit keluarga
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c. Genogram
VII. Perkembangan
a. Motorik Kasar
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b. Motorik halus
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b. Nutrisi
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c. Aktifitas
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f. Pola Hubungan
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g. Koping
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i. Konsep diri
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k. Nilai/kepercayaan
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IX. Pengkajian Head To Toe Kepala
Rambut :
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Kulit Kepala :
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Mata
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Hidung
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Mulut
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Telinga
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Leher
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Dada
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Paru
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Jantung
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Abdomen
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Genetalia
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X. Pemeriksaan Diagnostik Penunjang
a. Data Lab
b. Terapi
XI. Analisa Data
No Data Etiologi Masalah