Format Resume Asuhan keperawatan Anak

Tanggal masuk : .....................................................................

Tanggal Pengkajian: .....................................................................

Ruangan/kelas : .....................................................................
No. Kamar : .....................................................................

Diagnosa Masuk : .....................................................................

A. IDENTITAS

1. Nama :

2. Umur :

3. Jenis Kelamin :
4. Agama :
5. Suku/ Bangsa :

6. Pendidikan :
7. Pekerjaan :

8. Alamat :

9. Penanggung jawab : Asuransi/BPJS/Jamsostek/Sendiri

B. RIWAYAT SAKIT DAN KESEHATAN

1. Keluhan utama :

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2. Riwayat Penyakit sekarang :

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3. Riwayat Penyakit dahulu :

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4. Riwayat Kehamilan dan Kelahiran

a. Prenatal ..............

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b. Intranatal ..............
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c. Postnatal ...............
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5. Riwayat Allergi :

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6. Pertumbuhan dan perkembangan (lampirkan KPSP)

Interpretasi : ...........................................................................................................................................................................
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7. Riwayat Imunisasi :
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C. Pemeriksaan Fisik (Data Fokus)
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D. Pemeriksaan Penunjang

PEMERIKSAAN PENUNJANG
Laboratorium

Photo/ Radiologi

USG

Dan lain-lain

(Interpretasi di buat dilembar tersendiri)

E. TERAPI ..
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I. Analisa Data

Kemungkinan
No Data Penunjang Masalah
Penyebab

1 Data Subjektif :
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Data Objektif

Diagnosa Keperawatan

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2. ……………………………………………………………………………………………………………………………………………………

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