RESUME ASUHAN KEPERAWATAN DASAR

A. Identitas Pasien
Nama Pasien : ...........................................................
No RM : ...........................................................
Tempat Tanggal Lahir : ...........................................................
Umur : ...........................................................
Agama : ...........................................................
Alamat : ...........................................................
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Pekerjaan : ...........................................................
Jenis Kelamin : ...........................................................
Diagnosa Medis : ...........................................................
Tanggal Pengkajian : ...........................................................
Nama Penanggujawab : ..........................................................
Hubungan dengan pasien : ...........................................................

B. Data Fokus
DS : ...........................................................
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DO : ...........................................................
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Riwayat Penyakit Sekarang : ...........................................................
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Riwayat Penyakit Dahulu : ...........................................................

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C. Terapi Medis
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D. Data Penunjang
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E. Analisa Data
N Data Masalah Penyebab
o

F. Diagnosa Keperawatan
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G. Rencana Asuhan Keperawatan dan Evaluasi

(Format sesui pada Nursing Care Plan)