2lembar Asesmen Rawat Jalan OBSGIN

LABEL NA+A

PENGKAJIAN AWAL PASIEN RAWAT JALAN OBSTETRI DAN GINEKOLOGI I.PENGKAJIAN I.PENGKAJIA N KEPERAWAT KEPERAWATAN

Tanggal:____________ anggal:_ _____________ __ Jam:____ Anamnesa(S) Riw Riwayat yat penya enyak kit e!e e!ell"mny "mnya a :___ :_____ ____ ____ ____ ____ ____ ____ ___ ____ ___ Agam Agama a :________________   ______________________  ______________________ Pen#i#ikan Pen#i#ikan :________________  :________________  Peng$ eng$! !ata atan e! e!el"m el"mny nya a :__ :______ ______ ____ ___ _____ ______ ____ ____ __ Pek eke% e%&&aa aan n :__ :______ ______ ____ ____ ____ ____  __  Riwayat Ale%gi :_____________________ Telep$n :________________  'am! 'am!at atan an :___ :_____ ____ ____ ____ ____ ____ ___  _  Pik$l$gi :________________  Pemeriksaan(O) Peme%ikaan : TD:____mm('g N:____)(mnt BB:___kg TB:____*m Riwayat O!et%i : +e +ena%*,:______ Nye%i 'ai#:____ 'P'T:_____+en$pa"e:__  Riwayat ke,amilan : Ke,amil +a*am L( 'i#"p( -m"% Pen$l$n Peny"lit Se!a! an n$ pe%alin P +ati eka%ang( g Ke,amila kematia an wkt pe%alin n n meninggal an

Skala nye%i Riik$ &at", Masalah Perawat(A) +aala,   /ema Perencanaan(P)

:_______________________________________________________   :_______________________________________________________   : E.al"ai

:__________________________ :______________________________________ _________________________ _________________  ____   _________________________  ______________________________________ __________________________ __________________  _____  Nama0tan#a tangan pe%awat  ________________________   ________________________ 

II. PENGKAJIAN OKTER Anamnesa(S) Kel",an "tama :__________________________ :_______________________________________ _________________________ ________________  ____   _________________________  ______________________________________ __________________________ __________________  _____  Riwayat penyakit eka%ang :__________________________ :_______________________________________ _________________________ ________________  ____  Pemeriksaan(O) Peme%ikaan 1ik A!#$men :_______________________________________________________   A"k"ltai :_______________________________________________________   Peme%i eme%ik kaa aan n pen" pen"n& n&an ang g : ma*am peme%ikaan 'ail -SG   Ra#i$l$gi EKG   La!$%at$%i"m ia!n"sa(A) Diagn$a Ke%&a :__________________________ :_______________________________________ _________________________ ________________  ____  Diag Diagn$ n$a a Ban# Ban#in ing g :___ :_____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ___  _  :__________________________ :______________________________________ _________________________ _________________  ____  Tera#i(P)  _________________________  _____________________________________ _________________________ __________________________ __________________________ ______________________  _________   _________________________  _____________________________________ _________________________ __________________________ __________________________ ______________________  _________   _________________________  _____________________________________ _________________________ __________________________ __________________________ ______________________  _________   _________________________  _____________________________________ _________________________ __________________________ __________________________ ______________________  _________  Nama0tan#a tangan #$kte%

 _______________________   _______________________ 

LABEL NA+A

NO

TGL K-NJ-NG AN

RES-+E RAWAT JALAN DIAGNOSA KOD NA+A  TERAPI(PEN-NJANG(EDE DOKTER KASI I/D2 34

LABEL NA+A

PENGKAJIAN PASIEN RAWAT JALAN OBSTETRI GINEKOLOGI 5-LANGAN6 Tgl/jam

Anamnesa(S) & Pemeriksaan (O)

Diagnosa(A)

Terapi(P)

Nama 0 tan#a tangan #$kte%

Data I#entita Paien  Tn(Ny(Nn(S#%(An laki(Pe%emp"an

Laki2

Nama : 777777777777777777777777777777777777777777 7777 Nama $%ang t"a : 777777777777777777777777777777777777777777 7777 Alamat :7777777777777777777777  Tanggal La,i% : 7777777777777 -m"% : 777777777778 N$ Telp :7777777777777 Agama: 777777777788 Pen#i#ikan Te%ak,i%: 7777777777778 Peke%&aan Te%ak,i% :77777777777788 Kel",an : 777777777777777777777777777777777777777777 7778