YAYASAN KARYA HUSADA PARE KEDIRI AS

Y A YE D I R A N
I
STIKES KARYA HUSADA KEDIRI
K

Ijin Mendiknas RI No. 164/D/O/2005 Rekomendasi Depkes RI No. HK.03.2.4.1.03862

PROGRAM STUDI S1 ILMU KEPERAWATAN

K A

A
RY
A H U SA

D
Jl. Soekarno Hatta, Kotak Pos 153, Telp/Fax. (0354) 395203 Pare Kediri
Website: www.stikes-khkediri.ac.id

FORMAT RESUME POLIKLINIK

I. DATA UMUM

Nama : ……………………………………………………………
No. Register : ...........................................................................................
Umur : ……………………………………………………………
Jenis Kelamin : ……………………………………………………………
Agama : ............................................................................................
Suku Bangsa
: .............................................................................................
Bahasa : ............................................................................................
.
Alamat : ……………………………………………………………
Pekerjaan : ……………………………………………………………
Penghasilan : ………………… ………………………………………...
Status : ……………………………………………………………
Pendidikan Terakhir : ……………………………………………………………
Tanggal Pengkajian : ……………………………………………………………
Diagnosa Medis : ……………………………………………………………

II. DATA DASAR

Keluhan Utama datang ke Poliklinik:

…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………

Riwayat Penyakit Sekarang

: ................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................

Upaya yang telah dilakukan:

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

Riwayat Kesehatan Dahulu : .................................................................................

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

Riwayat Kesehatan Keluarga : .................................................................................

..........................................................................................................................................
III. Pemeriksaan Fisik ( B1 – B6 )

1) B1 (Breathing)

2) B2 (Bleeding)

3) B3 (Brain)

4) B4 (Bladder)

5) B5 (Bowel)

6) B6 (Bone)

V. Tindakan yang dilakukan di Poliklinik :

VI. Terapi yang diberikan saat di poliklinik:

Diagnosa Keperawatan :

Intervensi Keperawatan :

Implementasi :

Evaluasi :
S :

O :

A :

P :

Mahasiswa,
(.......................)