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KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN KEMENKES SURABAYA

PROGRAM STUDI DII KEPERAWATAN SIDOARJO

Jl. Pahlawan 173 A Telp. (031) 8921789 Sidoarjo

Format Resume

No Register : .............................. Tgl /Jam MRS : ………………….

Ruang : ................................. Tgl Pengkajian : ………………….

Diagnosa Medis : ...............................

1. IDENTITAS
a. Biodata Pasien
Nama : ………………………………………………....................
Jenis Kelamin : ………………………………………………....................
Umur : ………………………………………………....................
Agama : ………………………………………………....................
Suku Bangsa : ………………………………………………....................
Pendidikan : ………………………………………………....................
Pekerjaan : ………………………………………………....................
Alamat : ………………………………………………....................
b. Penanggung jawab
Nama : ………………………………………………....................
Jenis Kelamin : ………………………………………………....................
Agama : ………………………………………………....................
Pekerjaan Alamat : ………………………………………………....................
Hubungan dg px : ………………………………………………....................
2. RIWAYAT KESEHATAN
a. Keluhan utama

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

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

b. Riwayat penyakit sekarang

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

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

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

........................................................... . ................................................................................
c. Evaluasi
S

Mengetahui,

Pembimbing Keperawatan CI Kepala Ruangan …………..


RSU Al-Islam H.M Mawardi RSU Al-Islam H.M Mawardi

(…………………………………) (…………………………………)

Pembimbing Institusi Mahasiswa


Poltekkes Kemenkes Surabaya Poltekkes Kemenkes Surabaya
Prodi D3 Keperawatan Sidoarjo Prodi D3 Keperawatan Sidoarjo

(…………………………………) (…………………………………)

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