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Format laporan analisa kasus

1. Identitas klien
Nama :
Umur :
Alamat :
Jenis kelamin :
Pekerjaan :
No.RM :
Tgl. Masuk :
Tgl. Pengkajian :
2. Tindakan pra hospital

CPR NPT

Oksigen Suction

Infus bebat tekan

NGT bidai

ETT penjahitan

OPT obat-obatan

3. Triage
a. Keluhan utama :
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b. Riwayat keluhan utama:
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c. TTV
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d. Berat Badan
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4. Pengkajian primer : (pengkajian Airway, breathing, circulation, dan
disintegrity )
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5. Pengkajian sekunder ; (meliputi pengkajian riwayat keperawatan dan haed to
toe )
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6. Pemeriksaan penunjang (meliputi pemeriksaan laboratorium, rontrgen, CT
scan, dll)
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7. Terapi medikasi : (meliputi nama obat, jenis obat, dosis, rute pemberian )
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8. Diagnosa keperawatan
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9. Tindakan keperawatan dan evaluasi (SOAP)

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10. Evaluasi diri


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