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RESUME ASUHAN KEPERAWATAN DASAR

A. Identitas Pasien
Nama Pasien : .........................................................
No RM : .........................................................
Tempat Tanggal Lahir : .........................................................
Umur : .........................................................
Agama : .........................................................
Alamat : .........................................................
.........................................................
Pekerjaan : .........................................................
Jenis Kelamin : .........................................................
Diagnosa Medis : .........................................................
Tanggal Pengkajian : .........................................................
Nama Penanggujawab : .........................................................
Hubungan dengan pasien : .........................................................

B. Data Fokus
DS : .........................................................
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........................................................................................................
DO : .........................................................
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Riwayat Penyakit Sekarang : .........................................................
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Riwayat Penyakit Dahulu : .........................................................


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C. Terapi Medis
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D. Data Penunjang
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E. Analisa Data
No Data Masalah Penyebab

F. Diagnosa Keperawatan
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G. Rencana Asuhan Keperawatan dan Evaluasi


(Format sesui pada Nursing Care Plan)