PEMERINTAH KABUPATEN MINAHASA

DINAS KESEHATAN
UPT PUSKESMAS TOMPASO
Alamat : Desa Talikuran Kecamatan Tompaso, Kode Pos 95693
Email : puskesmastompaso18@.yahoocom

FORMAT PENGKAJIAN
DATA DASAR SEWAKTU MASUK PUSKESMAS
I. IDENTIFIKASI KLIEN
Inisial nama : ....................................................................................
Tempat/Tgl Lahir (umur) : ....................................................................................
Jenis Kelamin : Laki-laki Perempuan
Status Perkawinan : ....................................................................................
Agama : ....................................................................................
Kebangsaan/Suku : ....................................................................................
Pendidikan : ....................................................................................
Pekerjaan : ....................................................................................
Alamat Rumah : ....................................................................................
Dx. Medis : ....................................................................................
II. DATA UMUM
 Tgl..........Jam.......... Keluarga yang dapat dihubungi .............Telp ......................
 Masuk di ruangan ............... dari rumah sendirian .......... dari rumah dengan keluarga ......
jalan ........ Jalan .......... Emergensi ........... lainnya
 Alat yang digunakan : Kursi Rodan ....... brankard ........ ambulans
 Alasan masuk rumah sakit/keluhan utama
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 Riwayat Keluhan Utama
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 Faktor Pencetus
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 Lamanya
Keluhan...............................................................................................................................
 Timbulnya keluhan : ( ) bertahap
( ) mendadak
 Faktor yang memperberat
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 Upaya yang dilakukan untuk mengatasinya sendiri
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 Riwayat Pengobatan sebelumnya

Jenis Obat Dosis Dosis Sebelumnya Frekuensi

III. KEADAAN UMUM

A. Keadaan Sakit : Klien tampak sakit ringan / sedang / berat / tidak tampak sakit
Alasan : Tak bereaksi / baring lemah / duduk / aktif / gelisah / posisi tubuh
B. Tanda-Tanda Vital :
1. Kesadaan
 Kualitatif : compos mentis
Apatis
  Kuantitatif :
Skala coma glasgow : - Respon motorik :
- Respon verbal :
- Respon membuka mata :
2. Tekanan Darah : ............ mmHg
3. Suhu : ........... °C
4. Nadi : ............ x/mnt (kuat/lemah; teratur/tidak)
5. Pernafasan : Frekuensi .............. x/mnt
C. ANTROPOMETRI:
1. Lingkar lengan atas : ............. cm
2. Tinggi badan : ............. cm
3. Berat Badan : ............. kg
IV. PENGKAJIAN POLA FUNGSI KESEHATAN
1. PERSEPSI TERHADAP KESEHATAN MANAJEMEN KESEHATAN
 Riwayat Penyakit yang dialami :
...................................................................................................................................
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 Riwayat penggunaan
Tembakau :
Alkohol :
Alergi (Obat / Makanan / lainnya )
Data Objektif Observasi Penapilan Umun Klien
- Kebersihan Rambut : .....................................................
- Kulit Kepala : .....................................................
- Kebersihan Kulit : .....................................................
- Higiene rongga mulut : .....................................................
- Kebersihan Genitalia : .....................................................
- Kebersihan Anus : .....................................................
2. NUTRISI METABOLIK
A. Data Subjektif
- Diet Kusus .........................................
- Anjuran diet sebelumnya ........................ ya ; ...................... tidak
- Nafsu Makan : ............. normal ............meningkat ............. menurun ............
mual........... muntah : ........... stomatis
- Perubahan BB dalam 6 bulan terakhir : ....... tidak; ........ ya ....... kg (naik/turun)
- Kesulitan Menelan : ........ tidak, ........ ya
B. Data Objektif
 Pemeriksaan Fisik
- Keadaan rambut .....................................................................................................
- Hidrasi kulit .............................................................................................................
- Kuku .......................................................................................................................
- Palpebrae .................................................Conjungtiva...........................................
- Sclera .....................................................................................................................
- Hidung ....................................................................................................................
- Rongga mulut ..........................................Gusi.......................................................
- Gigi geligi ............................................... Gigi Palsu ..............................................
- Kemampuan mengunyah ......................................................................................
- Lidah ......................................................... Tonsil ..................................................
- Kelenjar getah bening leher ....................................................................................
- Kelenjar parotis .......................................... Kelenjar thyroid ...................................
- Abdomen
Inspeksi : .........................................................................................................
Auskultasi : .........................................................................................................
Palpasi : ..........................................................................................................
Kulit : ..........................................................................................................
 Pemeriksaan Diagnostik :
- Laboratorium :
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3. POLA ELIMINASI
A. Data Subjektif
a. Kebiasaan BAK
- Normal ........... , Frekuensi ...........
- Karakteristik Urine .....................................................................................................
- Masalah berkemih .....................................................................................................
b. Kebiasaan BAB ….........................................................................................................
B. Data Objektif
 Pemeriksaan Fisik
- Peristaltik usus : ........... x/mnt
- Palpasi suprapubika : Kandung kemih penuh kosong
- Nyeri ketuk ginjal :
Kiri : Negatif Positif
Kanan : Negatif Positif
4. POLA AKTIVITAS DAN LATIHAN
A. Observasi
- Kemampuan perawatan diri
Skor : 0= mandiri, 1= dibantu sebagian, 2= perlu bantuan orang lain, 3= perlu
bantuan orang lain dan alat, 4= tergantung/tidak mampu
Makan :
Mandi :
Berpakaian :
Eliminasi :
Mobilisasi di tempat tidur :
5. POLA ISTIRAHAT DAN TIDUR
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