FORMAT RESUME

Hari/Tanggal Pengkajian:
Inisial Klien : ...........................................
Tanggal Masuk : ..........................................
No RM : ...........................................
Diagnosa Medis : ..........................................

A. Riwayat Masuk RS
...........................................................................................................................................................
...........................................................................................................................................................
..........................................................................................................................................................

B. Pengkajian Saat Ini

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

C. Pemeriksaan Penunjang dan Laboratorim

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

D. Masalah Keperawatan
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
................................................................................................................................... ......................

E. Intervensi dan Implementasi

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 LOG BOOK
Nama : ………………………….....................................
NIM : ………………………….....................................
RS : .............................................................................

Waktu Target Kegiatan Pencapaian Kompetensi Di Mandiri Preceptor

Kompetensi
Hari, Bimbing
TGL, Jam

Contoh: Melakukan - Melakukan pengkajian anatomi lapisan Diceklis Diceklis Komentator

Hari..... pengkajian kulit saat perawatan luka. Pemeriksaan /paraf
anatomi fisik pada Bp. A dengan diabetes
Tgl:....... melitus. Dari hasil observasi didapat
lapisan kulit
data luka mencapai lapisan dermis pada
saat tumit kaki sebelah kiri dengan ciri-ciri:
Jam...........
perawatan terjadi perdarahan saat disentuh, rasa
.
luka nyeri pada bagian luka

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