RM7/rev3/2000/X/2016

PEMERINTAH KOTA TASIKMALAYA

RUMAH SAKIT UMUM DAERAH dr. SOEKARDJO
Jln. Rumah Sakit No. 33 Tasikmalaya Telp. 0265 - 331683

RESUME KEPERAWATAN

Bangsal :

Nomor RM :

Nama :

Umur

th/bl/hr

Berikan tanda pada kotak yang dipilih

Bio sosial
Tanggal Masuk
Tanggal Keluar
Jenis kelamin
Agama
Pekerjaan
Alamat Lengkap

: .......................................................................................................
: .......................................................................................................
: .......................................................................................................
:
L
P
:
Islam
Kristen
Hindu
Budha
: .......................................................................................................
: .......................................................................................................
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1. Status Pulang
Atas izin dokter
Dirujuk
Melarikan diri
Meninggal dunia
Atas permintaan sendiri
2. Keadaan umum saat pulang
Suhu
: ........................C
Nadi
: ........................ Mmhg
Kesadaran
: ........................
BB
: ........................ Kg Nadi
: ........................ x / Menit BB
3. Alat bantu yang masih terpasang saat pulang
Tidak ada
Kateter
Oksigen
Infus
NGT (Naso Gastric Tube)
Lain-lain
4. Masalah keperawatan pada saat pasien dirawat :
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5. Tindakan keperawatan yang dilaksanakan selama pasien dirawat
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6. Evaluasi keperawatan
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7. Penyuluhan kesehatan :
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8. Data hasil pemeriksaan penunjang dan surat keterangan yang diserahkan pada pasien waktu pulang :
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9. Obat yang dibawa saat pasien pulang
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10. Pulang ke alamat
: ..................................................................................................................................
11. Nama penjemput
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12. Hubungan dengan pasien
: ..................................................................................................................................
Tanda tangan
Kepala Ruang Rawat
Pasien / Keluarga
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NIP :

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.Form

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