RESUME ASUHAN KEPERAWATAN DASAR

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

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

Riwayat Penyakit Dahulu : .................................................................

.....................................................................................................................
.....................................................................................................................
C. Terapi Medis
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

D. Data Penunjang
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
E. Analisa Data
No Data Masalah Penyebab
F. Diagnosa Keperawatan
.....................................................................................................................
.....................................................................................................................
G. Rencana Asuhan Keperawatan dan Evaluasi
DIAGNOSA
HARI/ TGL TUJUAN INTERVENSI RASIONAL
KEPERAWATAN