A.

Identitas Pasien
Nama :
Umur :
Jenis Kelamin :
Agama :
Alamat :
Pendidikan :
Pekerjaan :
Tgl. Masuk RS :
Tgl. Pengkajian :
No CM :
Dx Medis :
B. Alasan Masuk
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C. Faktor Predisposisi
1. Pernah mengalami gangguan jiwa di masa lalu?
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2. Pengobatan sebelumnya?
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3. Trauma ?
a) Jenis trauma
b) Pelaku
c) Usia saat trauma
 4. Adakah anggota keluarga yang mengalami gangguan jiwa?
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5. Pengalaman masa lalu yang tidak menyenangkan
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D. Aspek Medik
a. Diagnosa Medis
b. Terapi medis
E. Analisa Data
DATA MASALAH
DS :
DO :

F. Daftar Masalah

G. Rencana Asuhan Keperawatan

Tanggal Diagnosa Tujuan dan Kriteria Rencana Tindakan dan
Hasil Rasional
H. Implementasi dan Evaluasi
Tanggal Diagnosa Tujuan/ target Implementasi Respon Klien Evaluasi