FORMAT RESUME ASUHAN KEPERAWATAN

INTRAOPERATIF

Nama mahasiswa :
Tempat Praktek :
Tanggal :

I. Identitas diri klien

Nama : Suku :
Umur : Pendidkan :
Jenis Kelamin : Pekerjaan :
Alamat : Lama bekerja :
Tanggal masuk RS : Tgl. Pengkajian :
Status perkawinan : Agama :
Sumber Informasi : No. CM :

II. Riwayat penyakit

1. Keluhan utama saat masuk RS : ………………………….
2. Riwayat penyakit sekarang :
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3. Ringkasan Perjalanan Operasi : (Uraikan perjalanan operasi mulai dari waktu dimulainya premedikasi s/d
Pasien keluar dari kamar operasi)
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4. Asuhan Keperawatan Intraoperatif : (Diagnosa Keperawatan Utama)
Diagnosa Keperawatan : ……………………………………………………………..
Data : …………………………………………………………………………………..
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Tindakan Keperawatan :
1. ………………………………………………………………………………..
2. ………………………………………………………………………………..
3. ………………………………………………………………………………..
4. ………………………………………………………………………………..
Evaluasi (SOAP) :
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…………………, ………,………..2017

Instruktur Klinik Mahasiswa

(………………….) (……………………….)
NIP………………… NIM……………………..