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Nama :

STIKES Hafshawaty NIM :


Pesantren Zainul HasanProbolinggo Poli :
RESUME KEPERAWATAN
Pada Tn/Ny/Sdr.........Dengan Kasus .....................

Data diambil tanggal :……………………. Jam………


No. Rekam Medik :…………………….

I. IDENTITAS KLIEN
Nama :……………………………………………………………………..
Umur :…………………………………………………………………….
Jenis Kelamin :…………………………………………………………………….
Suku / Bangsa :………………………………………………………………………
AgamaPekerjaan :………………………………………………………………………
Pendidikan :………………………………………………………………………
Alamat :………………………………………………………………………
No. Register :…………………………………………………………………….
Tanggal MRS :………………………………………………..............................
Diagnosa Medis :………………………………………………..............................
Sumber Informasi :………………………………………………..............................
Penanggung : Askes / Astek / Jamsostek / JPS / Sendiri

II. KELUHAN UTAMA


……………………………………………………………………………………………………………….................……………..

III. RIWAYAT PENYAKIT SEKARANG


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IV. PEMERIKSAAN FISIK FOKUS PADA KASUS


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V. PEMERIKSAAN DIAGNOSTIK / PENUNJANG


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VI. ASUHAN KEPERAWATAN


S : .......................................................................................................................................................................................
O : .......................................................................................................................................................................................
A : .......................................................................................................................................................................................
P : .......................................................................................................................................................................................
I : .......................................................................................................................................................................................
E : .......................................................................................................................................................................................

Keterangan :
S : Data Subyektif dari pasien atau keluarga.
O : Data Obyektif dari hasil pemeriksaan pengkajian dan pemeriksaan diagnostik.
A : Assasment/ Diagnosa Keperawatan
P : Rencana keperawatan
I : Tindakan keperawatan
E : Evaluasi Keperawatan

............................, ..............................2020
Mahasiswa,

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