RESUME ASUHAN KEPERAWATAN JIWA

PADA PASIEN _________ DENGAN_______________________

TANGGAL __________________________
DI RUANG _________ RS JIWA PROPINSI BALI

OLEH :

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PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA
2012

Resume Asuhan Keperawatan Pada ...............................................

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A. Identitas Pasien
Nama

No RM

Umur

Tgl MRS :

Jenis Kelamin

Dx Medis :

Alamat

B. Keadaan Umum
Keadaan Umum :
TTV

:
- TD =
- N =
- RR =
- T

C. Riwayat Masuk RS
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D. Data Fokus

S : (Data Subjektif)
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O : (Data Objektif)
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A : (Diagnosa Keperawatan)
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P (rencana keperawatan pada hari itu diperlukan untuk mengatasi diagnosa point
A)
Hari /
Tgl

No
Dx

Rencana Keperawatan
Tujuan dan Kriteria
Hasil

Intervensi

Rasional

 I (Implementasi pada hari itu)

Hari /
Tgl

No
Dx

Jam

Tindakan Keperawatan

Respon Klien

TTD

 E (Evaluasi hari itu untuk masalah point A)

No

Hari / Tgl

No Dx

Jam

Evaluasi

TTD

Mengetahui

Denpasar, ......................... 2012

Pembimbing

Mahasiswa

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