FORMAT LAPORAN RESUME

Tanggal/ Tempat Pengkajian : ............................

Nama Pengkaji : ............................

A. Data biografi

Nama : .......................................................................... L / P
Tempat & Tanggal lahir : ................................... Gol. Darah : O / A / B / AB
Pendidikan terakhir : ..........................................................................................
Agama : Islam/ Protestan/ Katolik/ Hindu/ Budha/ Konghucu/ LL
Status Perkawinan : Kawin / Belum / Janda / Duda (Cerai : Hidup / Mati )
TB/BB : ......................... Cm/ ................. Kg
Penampilan : .................... Ciri-ciri tubuh : ......................................
Alamat : .......................................................................................
.......................................................................................Telp. ........................................
Orang yang dekat dihubungi : .......................................................................................
Hubungan dengan usila : .......................................................................................
Alamat : .......................................................................................

B. Alasan Masuk
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

C. Analisa Data

Data Interpretasi Masalah

(sign / Symptom) (Etiologi) (Problem)

D. Diagnosa Keperawatan
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
E. Rencana Keperawatan

No. Hari/Tgl/J Diagnosa Perawatan TUJUAN INTERVENSI RASIONAL

am

F. Implementasi dan Evaluasi Keperawatan

HARI/TGL DX. TINDAKAN EVALUASI TINDAKAN TTD/NAMA

PUKUL KEP. KEPERAWATAN PERAWAT
S:

O:

A:

P: