RESUME FORMAT LAPORAN OK

A. Biodata

1. Identitas
Nama :
Umur :
Jenis kelamin :
Alamat :
Pekerjaan :
Agama :
Diagnosa medis :
Tanggal pengkajian :
2. Identitas Penanggung Jawab
Nama :
Umur :
Jenis kelamin :
Alamat :
Pekerjaan :
Agama :
Hubungan dengan klien :

B. Rencana Tindakan

C. Diagnosa Medis Pra Bedah :

D. Diagnosa Medis Pasca bedah :

1. Pre Operatif
a. Fokus Pengkajian
1. Riwayat Kesehatan
a) Keluhan Utama
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b) Riwayat Penyakit Sekarang
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c) Riwayat Penyakit Keluarga
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d) Riwayat Penyakit Dahulu
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e) Riwayat Penyakit Alergi
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2. Psikospiritual
a. Kecemasan Pra Operatif
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b. Perasaan
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 c. Pola Pertahanan Diri atau Koping
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d. Spiritual
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e. Pengetahuan
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3. Status Nutrisi
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4. Status Respirasi
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5. Status Eliminasi
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6. Tanda-tanda Vital
TD : mmHg N: x/Menit RR : x/Menit S: C
E. Analisa Data

DATA ETIOLOGI MASALAH

F. DIAGNOSA KEPERAWATAN

1. ............................................................................................................................

2. ............................................................................................................................
 G. RENCANA KEPERAWATAN

No DIAGNOSA NOC NIC

 H. IMPLEMENTASI

NO Hari/ JAM Dx IMPLEMENTASI TTD

Tanggal
 I. EVALUASI

Hari/Tanggal :
JAM No. Dx SOAP TTD
7. Intra Operatif
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a. Persiapan Pasien di Ruang Bedah
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b. Laporan Kegiatan Operasi (dari awal sampai akhir)
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8. Post Operatif

a. Fokus Pengkajian

1. Pengkajian Awal :
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2. Status Kesadaran :
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3. Sistem Pernafasan :
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4. Status Sirkulasi :
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5. Status Neurologi :
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6. Kontrol Suhu :
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7. Respon Nyeri :
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8. Status Gastrointestinal :
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9. Keseimbangan Cairan dan Elektrolit :
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10. Integritas Kulit, Kondisi Luka, Dan Drainase :
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11. Instruksi Post Operatif :
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J. Analisa Data

DATA ETIOLOGI MASALAH

K. DIAGNOSA KEPERAWATAN

3. ............................................................................................................................

4. ............................................................................................................................
 L. RENCANA KEPERAWATAN

No DIAGNOSA NOC NIC

 M. IMPLEMENTASI

NO Hari/ JAM Dx IMPLEMENTASI TTD

Tanggal
 N. EVALUASI

Hari/Tanggal :

JAM No. Dx SOAP TTD