2019 - Catatan Keperawatan.docx

CATATAN KEPERAWATAN KUNJUNGAN RAWAT JALAN PUSTU TUMBANG SALIO KECAMATAN PERMATA INTAN

I. PENGKAJIAN A. BIODATA 1.Identitas Pasien Nama

:

Umur

:

Jenis Kelamin

:

Status Perkawinan

:

Agama

:

Suku

:

Pendidikan

:

Pekerjaan

:

No. Register

:

Diagnosa Medik

:

Tanggal Masuk

:

Tanggal Pengkajian

:

Alamat

:

B. KELUHAN UTAMA ............................................................................................................................................... ............................................................................................................................................... ...............................................................................................................................................

C. RIWAYAT KESEHATAN SEKARANG ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... D. RIWAYAT KESEHATAN DAHULU ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ...............................................................................................................................................

TANGGAL

WAKTU

MASALAH

S.O.A.P.I.E.R

S (Subjective) :

O (Objective) :

A (Analisis) :

P (Planning) :

I (Implementation) :

E (Evaluation) :

R (Revised) :

Tumbang Salio, .... ...................... 2018 Petugas Pustu Tumbang Salio

ARIF KURNIAWAN, Amd.Kep NIP. 19840317 200804 1 003

Mengetahui, Kepala Puskesmas Tumbang Lahung

dr. RIA FRANSISKA HARIANJA NIP.19750917 200903 2 002