FORMAT LAPORAN PENDAHULUAN

1. Definisi
2. Etiologi
3. Tanda dan gejala, Klasifikasi
4. Patofisiologi (bagan/alur)
5. Pemeriksaan penunjang
6. Penatalaksanaan
7. Masalah keperawatan dan data pendukung
8. Diagnosa keperawatan yang mungkin timbul(minimal 3 diagnosa eperawatan)
9. Tujuan rencana keperawatan perdiagnosa keperawatan dan Kriteria hasil
10 Intervasi keperawatan & rasional perdiagnosa keperawatan
11.Daftar Pustaka

FORMAT LAPORAN ASUHAN KEPERAWATAN LENGKAP

1. Laporan Pendahuluan
2. Pengkajian (termasuk format pengkajian)
3. Analisa data (data subyektif&obyektif, etiologi, masalah keperawatan, diagnose keperawatan)
4. Prioritas diagosa keperawatan
5. Rencana keperawatan
6. Implementasi
NO Tgl/jam DX IMPLENTASI PARAF

7. Evaluasi
 RESUME KEPERAWATAN ANAK

NAMA :
USIA :
RIWAYAT IMUNISASI :
JENIS KELAMIN :
RUANG :
TANGGAL MASUK RS :
1. Riwayat Kesehatan sebelumnya
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2. Kesehatan Sekarang
- Alasan Utana Masuk RS
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- Keluhan Saat Ini
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- Diagnosa Keperawatan
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- Intervensi Keperawatan
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- Implementasi
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- Evaluasi
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