RESUME UJIAN

PADA PASIEN .........

DENGAN .......................................

DI RUANG .............................................................

TANGGAL, .........................................................

1. Pengkajian
A. Identitas pasien
Nama :
Umur :
Jenis kelamin :
Status :
Alamat :
Agama :
No.RM :

B. Riwayat kesehatan :
Keluhan utama MRS
.................................................................................................................................
.................................................................................................................................
Keluhan utama saat pengkajian
.................................................................................................................................
.................................................................................................................................
Riwayat penyakit sebelumnya
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
Riwayat penyakit sekarang
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
C. Pola kebiasaan (SESUAIKAN DENGAN KASUS)
1) ............ :
Sebelum pengkajian
...........................................................................................................................
...........................................................................................................................
Saat pengkajian
...........................................................................................................................
...........................................................................................................................

D. Pemeriksaan fisik ( SESUAIKAN DENGAN KASUS, YG

BERMASALAH?)
CONTOH : DX CHF
1) Thorax
Inspeksi :
...........................................................................................................................
...........................................................................................................................
Palpasi :
...........................................................................................................................
...........................................................................................................................
Perkusi
...........................................................................................................................
...........................................................................................................................
Auskultasi
...........................................................................................................................
...........................................................................................................................

E. Pemeriksaan penunjang
Lab, dll

F. Data fokus
Data subjektif Data objektif Masalah
- Px - Px .........
mengatakan........... - Px...
- Px - Px...........
- Px
 G. Analisa data
Data subjektif Data objektif Masalah
- Px .... - Px......... ........................
- Px...... - Px........... ........................
- Px....... - Px.........

Rumusan masalah
P:..................
E:........................
S:................................

Proses terjadi :
.................................................................................................................................
.................................................................................................................................
Akibat jika tidak ditanggulangi :
.................................................................................................................................
.................................................................................................................................

2. Diagnosa keperawatan
Nama :
Umur :
Jenis kelamin :
Diagnosa medis :

Diagnosa Tanggal Paraf

keperawatan ditemukan tindakan
3. Perencanaan
Rencana keperawatan pada ........
Dengan.........
Diruang ....................
Tgl ................

Hari / dx.kep Tujuan dan Intervensi Rasional

tgl/ jam kriteria hasil
1x24 jam

4. Implementasi
No Hari / dx. kep Implementasi Evaluasi
tgl /
jam
Ds :
Do :

5. Evaluasi
Hari / tgl Dx kep Evaluasi
/ jam
S:
O:
A:
P:
LEMBAR PENGESAHAN