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FORMAT LAPORAN

RESUME KEPERAWATAN JIWA


1. PENGKAJIAN
A. IDENTITAS KLIEN
Nama (Inisial) :
L/P
:
Umur
:
Alamat
:
Pendidikan :
Agama
:
No. RM
:
Tgl Pengkajian :
B. ALASAN MASUK
.......................................................................................................................................
.......................................................................................................................................
........................................................................................................................
C. PEMERIKSAAN FISIK
Keadaan umum
:
TD
:
Nadi
:
Respirasi
:
Suhu
:
Keluhan fisik
:
D. DATA FOKUS
DATA SUBYEKTIF
DATA OBYEKTIF

E. ANALISA DATA
N
o
1.

DATA

ETIOLOGI

Subyektif
.

Obyektif

2.

Subyektif
.

Obyektif

PROBLEM

F. DAFTAR DIAGNOSA KEPERAWATAN (PRIORITAS)


1. ............................................................................................................................
2. ............................................................................................................................
G. RENCANA INTERVENSI KEPERAWATAN
NO
TGL/JA
M

DIAGNOSA
KEPERAWATAN

NOC

NIC

H. IMPLEMENTASI DAN EVALUASI


NO
TGL/JA
M

IMPLEMENTASI

EVALUASI FORMATIF

EVALUASI SUMATIF