RESUME

PADA PASIEN .................................................................

DENGAN DIAGNOSA MEDIS ..............................
DI POLI ..................................................

DEPARTEMEN

MATERNITAS

Disusun Oleh:

...............................................

PROGRAM STUDI PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN
INSAN CENDEKIA MEDIKA
JOMBANG
2017
 PRAKTIK PROFESI NERS
PROGRAM STUDI PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN
INSAN CENDEKIA MEDIKA JOMBANG
Jl. Kemuning No. 57 A Candimulyo Jombang, Telp. 0321-8494886
Email: stikes.icme@yahoo.com

Resume pada pasien.........................................................

Dengan Diagnosa Medis ..................................
di Poli ...............................................

I. PENGKAJIAN
A. Tanggal Pengkajian :.........................................................................................................
B. Jam Pengkajian :.........................................................................................................
C. No.RM :.........................................................................................................
D. Identitas
1. Identitas pasien
a. Nama : ...............................................................................................
b. Umur : ...............................................................................................
c. Jenis kelamin : ...............................................................................................
d. Agama : ...............................................................................................
e. Pendidikan : ...............................................................................................
f. Pekerjaan : ...............................................................................................
g. Alamat : ...............................................................................................
h. Status Pernikahan : ...............................................................................................

E. Riwayat Kesehatan
1. Keluhan Utama
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 2. Riwayat Kesehatan Sekarang
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3. Riwayat Kesehatan Dahulu
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4. Riwayat Kesehatan Keluarga
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F. Pengkajian
a. Keadaan Umum
b. Vital Sign
Tekanan Darah : .......................... Nadi : ............................
Suhu : .......................... RR : ............................
c. Kesadaran : .......................................................................
GCS : .......................................................................
d. Pemeriksaan Fisik
G. Diagnosa Keperawatan