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ASESMEN DOKTER

1.ANAMNESIS:
1.Keluhan Utama:....................................................................................................................................................................................
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2.Keluhan Tambahan:.............................................................................................................................................................................
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3.Riwayat Penyakit Darurat dan eran:....................................................................................................................................................
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4.Riwayat Penyakit Keluarga: Tidak ada Ada

Hipertensi DM Penyakit jantung TBC Epilepsi Kelainan bawaan Alergi

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II.PEMERIKSAAN FISIK:
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III.HASIL PEMERIKSAAN PENUNJANG:
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IV.DIAGNOSIS:
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V.RENCANA KERJA (EDUKASI,TERAPI DAN DIAGNOSTIK):
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VI.TINDAK LANJUT:
Pulang

MRS

Dikonsulkan..........................................................................................

Dirujuk Ke............................................................................................

Datang Kembali Tanggal......................................................................

Alasan......................................................................................................

Dokter Penanggung Jawab Pelayanaan

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Nama Jelas dan Tanda Tangan
ASESMEN AWAL PASIEN RAWAT JALAN
Jenis Kelamin : -L/P
PASIEN GERITARI

I. Asesmen Keperawatan
Tanggal Asesmen : ……………………… Jam Asesmen : ……………………………………………………………………………………………………………….
Data diperoleh dari : Pasien Keluarga
1. Data Awal : a. Keluhan Utama : ……………………………………………………………………………………………………………………………………….
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b. Keadaan Umum : ……………………………………………………..……………………………………………………………………………….
c. Kesadaran : ……………………………………………………………………………………………….……………………………………..
d. TTV : TD : ……mmHg. Nadi : …….x/menit Suhu : …..C. RR:.….x/menit
e. Antropometri : BB : ……Kg
2. Riwayat Penyakit : Tidak ada Ada, Sebutkan ……………………………………………………………………………..………………………………..
3. Riwayat Alergi Obat/Makanan : Tidak Ada Ada, sebutkan ……………………………………………………………..……….…………………
4. Status Sosial Ekonomi : Pekerjaan : PNS TNI/POLRI Pensiun Lainnya…………………………………………………………….
Status Ekonomi : Biaya Sendiri Asuransi/Perusahaan………………………………………….……………………
Agama: Islam Hindu Budha Katolik Kristen Konghucu
Keyakinan/Kepercayaan ……………………………………………………………………………………………….……………………..
5. Status Psikologis : Cemas Takut Marah Sedih Kecenderungan Bunuh Diri Lainnya ………………………………..……
6. Skrining Nyeri : Adakah keluhan nyeri? Tidak Ada Ada Ringan 1-3 Sedang 4-6 Berat 7-10
8. Assesmen Risiko cedera /jatuh berdasarkan Time Up and Go

9. Status Fungsional (Berdasarkan Penilaian Barthel Index Modified)

10. Skrining Nutrisi Berdasarkan Mini Nutritional Assesment / MNA


Skor : ………. Keterangan : 12-14 : Status Gizi Normal
8-11 : Berisiko Malnutrisi
0-7 : Malnutrisi
11. Penilaian Status Mental Berdasarkan Short Portable Mental Status Questionnaire / SPMSQ
Total Jawaban salah : …………. Keterangan : Salah 0-3 : Fungsi intelektual baik
Salah 4-5 : Kerusakan intelektual ringan
Salah 6-8 : Kerusakan intelektual sedang
Salah 9-10 : Kerusakan intelektual berat
12. Penilaian Skala Depresi Berdasarkan Geriatric Depression Scale / GDS
Total Jawaban yang sesuai : …………. Keterangan : Skor jawaban yang sesuai 0-4 : Tidak ada depresi
Skor jawaban yang sesuai 5-9 : Kemungkinan depresi
Skor jawaban yang sesuai > 10 : Depresi
13. Kebutuhan Edukasi : Terdapat gangguan daya ingat : Tidak ada Ada …………………………………………………………………………….
Terdapat hambatan dalam pembelajaran : Tidak ada Ada …………………………………………………………………………….
Dibutukan Penerjemah : Tidak Ya, Sebutkan……………………………………………………………….
Kebutuhan Pembelajaran Pasien :
14. Masalah Keperawatan : PPJA
No Masalah Keperawatan Tujuan / Target Terukur Rencana Keperawatan

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Nama jelas dan Tanda Tangan