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RESUME KEPERAWATAN

PRAKTIK RAWAT JALAN

Nama

: ................................................................................................................

No. Rekam Medik

: ................................................................................................................

Umur

: ...............................................................................................................

Bangsal / Ruang

: ................................................................................................................

Jenis Kelamin

: ........................................

Tgl. Masuk RS

: ...............................................................................................................

Tgl. Keluar RS

: ............................................

Agama

: ..............................................................................................................

Alamat

: ................................................................................................................

Diagnosa Medis

: ......................................

I.

II.

Keluhan Utama

Riwayat Penyakit Sekarang

III.

Riwayat Penyakit Dahulu

IV.

Pemeriksaan Diagnostik

V.

PEMERIKSAAN FISIK
A. Keadaan umum klien

B. Tanda tanda vital

VI.

VII.

Suhu

: ........ oC

Nadi

: ........ x / menit

Pernafasan

: ........ x / menit

T.D.

: ........ /......... mmHg

TERAPI YANG DIBERIKAN

DIAGNOSA KEPERAWATAN PADA SAAT PASIEN DIRAWAT