FORMAT RESUME KASUS KELOLAAN HARIAN

1. Identitas Pasien
a. Nama

b. Umur

: . tahun

c. Jenis kelamin

d. Status

e. Agama

f. Pekerjaan

g. Alamat

h. RM

i. Diagnosa Medis

j. Tanggal masuk RS

jam : . WIB

k. Tanggal pengkajian

jam : . WIB

2. RIWAYAT KESEHATAN
a. Keluhan utama:

b. Riwayat kesehatan sekarang:

c. Riwayat kesehatan klien sebelumnya:

d. Pengkajian head to toe (DATA FOKUS)

3. CATATAN PERAWATAN & PERKEMBANGAN KLIEN HERE AND

NOW

S (Subjektif):
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O (Objektif):
............................................................................................................
...................................................................
A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS
dan DO):
............................................................................................................
...................................................................
............................................................................................................
...................................................................
P(Perencanaan):
............................................................................................................
...................................................................
............................................................................................................
.................................................................
I (Implementasi):
............................................................................................................
...................................................................
............................................................................................................
...................................................................
E (Evaluasi):
S (Subjektif)
: ..........................................................................................................
.....................................................................
............................................................................................................
...................................................................
O
(Objektif): ...........................................................................................
....................................................................................
............................................................................................................
...................................................................
A (analisa) :
............................................................................................................
...................................................................
............................................................................................................
...................................................................
P
(Perencanaan: ....................................................................................
...........................................................................................

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