RESUME

STASE KEPERAWATAN DASAR PROFESI

I. IDENTITAS KLIEN
Nama : …………………… Suku : …………………………
Tanggal lahir/Umur : …………………… Tgl masuk : …………………………
Jenis kelamin : …………………… Tgl dikaji : …………………………
Alamat : …………………… Ruang perawatan: …………………...
Pendidikan : …………………… Diagnosa medis : ……………………
Agama : …………………… No. Rekam Medis : ………………….

Identitas Penanggung jawab

Nama : …………………… Alamat : …………………………
Umur : …………………… Pendidikan : …………………………
Jenis kelamin : …………………… Pekerjaan : …………………………
Suku/bangsa : …………………… Hubungan : …………………………

II. PENGKAJIAN
a. Keluhan Utama:
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b. Riwayat Penyakit Dahulu:
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c. Riwayat Penyakit Sekarang:
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d. Riwayat Keluarga: Genogram:

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III. DATA FOKUS

A. Data Subjektif
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B. Data Objektif
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C. Hasil Lab/ dll

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IV. Analisis Data

DATA KLIEN MASALAH

No ETIOLOGI
(Data Subjektif & Data Objektif) KEPERAWATAN
V. Diagnosa Keperawatan
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Rencana Keperawatan
Diagnosa Perencanaan
No
Keperawatan Tujuan Keperawatan & NOC Intervensi Keperawatan (NIC)
Implementasi dan Evaluasi
Hari/ Nomor Dx Implementasi Evaluasi
Jam TTD
Tgl Keperawatan Keperawatan Keperawatan