FAKULTAS KEPERAWATAN UNIVERSITAS JEMBER

FORMAT RESUME KEPERAWATAN MATERNITAS ANAK

Nama Mahasiswa :
NIM :
Tanggal resume :

FORMAT RESUME KASUS KELOLAAN HARIAN

IDENTITAS PASIEN
Nama :
Tanggal Lahir :
Jenis Kelamin :
Agama :
Pendidikan :
Pekerjaan :
Alamat :
No. RM :
Ruangan :
Diagnosa Medis :

1. Defisini Penyakit
2. Etiologi
3. Tanda dan Gejala
4. Pathway

S (Subjektif):
............................................................................................................................................................................................
............................................................................................................................................................................................
O (Objektif):
............................................................................................................................................................................................
............................................................................................................................................................................................
............................................................................................................................................................................................
1. Head To toe :
2. B1 – B6 :
B1 (breathing)
B2 (blood)
B3 (brain)
B4 (Bladder)
B5 (Bowel)
B6 (Bone)
A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasarkan DS dan DO):
No Data Subjektif & Data Objektif Etologi Masalah / Diagnosa
1 DS :
DO :
2 DS :
DO :
3 DS :
DO :

P(Perencanaan):
No Diagnosa Intervensi Rasional Nama & Paraf

I (Implementasi):
No Diagnosa Implementasi Nama & paraf

E (Evaluasi):
No Diagnosa Evaluasi Paraf & Nama
S
O
A
P
S
O
A
P
S
O
A
P