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LAPORAN RESUME KASUS

KEPERAWATAN MEDIKAL BEDAH


Ruangan : ……………………………………
Diagnosa Medis : ……………………………………
Tanggal Pengkajian : ……………………………………
I. PENGKAJIAN
A. Identitas Pasien
Nama : …………………………………….
Umur : …………………………………….
Pendidikan : …………………………………….
Suku Bangsa : …………………………………….
Pekerjaan : …………………………………….
Agama : …………………………………….
Alamat : …………………………………….
No. Medical Record : …………………………………….
Tanggal Masuk : …………………………………….
Tanggal Pengkajian : …………………………………….
B. Penanggung Jawab
Nama : …………………………………….
Pekerjaan : …………………………………….
Alamat : …………………………………….
Hubungan Dengan Pasien : …………………………………….
C. Riwayat Kesehatan Sekarang
1. Riwayat Kesehatan Sekarang
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2. Riwayat Kesehatan Dahulu
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3. Riwayat Kesehatan Keluarga
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D. Pemeriksaan Fisik
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E. Pemeriksaan Penunjang
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F. Terapi
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II. ANALISA DATA
Data Fokus Penyebab
No Masalah
(subjektif dan Objektif) (Patofisiologi)

III. DIAGNOSA KEPERAWATAN


NO DAFTAR DIAGNOSA KEPERAWATAN TANDA TANGAN

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IV. RENCANA KEPERAWATAN
NO TANGGAL/JAM DIAGNOSA KEPERAWATAN NOC NIC AKTIVITAS

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Format Resume KMB praktek profesi STIKES SYEDZA SAINTIKA Padang