FORMAT RESUME KASUS

PROGRAM STUDI SARJANA TERAPAN KEPERAWATAN

POLITEKNIK KESEHATAN KEMENKES KALTIM

A. Identitas Klien
Nama :
Tanggal Lahir :
Jenis Kelamin :
Status Perkawinan :
Agama :
Alamat :
Tgl & jam Masuk RS :
Tanggal Pengkajian :
Dx. Medis :
No. Register :
B. Pengkajian
1. Keluhan Utama :
2. Riwayat Penyakit Sekarang :
3. Riwayat Penyakit Dahulu :
4. Riwayat Penyakit Dalam Keluarga :
5. Pemeriksaan TTV & Fisik :
6. Pemeriksaan Penunjang :
C. Data Fokus
D. Rencana Asuhan Keperawatan
1. Dx. Keperawatan
2. Tujuan
3. Kriteria hasil
4. Intervensi (Pkl...Wita)
5. Implementasi (Pkl...Wita)
E. Evaluasi SOAP (Pkl...Wita)
 RESUME ASUHAN KEPERAWATAN
PRAKTIK KEPERAWATAN KLINIK 2 (KMB I)
PROGRAM STUDI SARJANA TERAPAN KEPERAWATAN

NAMA MAHASISWA : .........................................................

NIM : .........................................................
TINGKAT/SEMESTER/JALUR : .........................................................
RS/RUANG : .........................................................

A. Data Umum
A. Biodata Klien :
Nama Pasien (Inisial) : ..........................................................................................................
JenisKelamin : ..........................................................................................................
Status Perkawinan : ..........................................................................................................
Agama : ..........................................................................................................
PendidikanTerakhir : ..........................................................................................................
Pekerjaan : ..........................................................................................................
Suku : ..........................................................................................................
Alamat : ..........................................................................................................
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TanggalMasukRS : ..........................................................................................................
TanggalPengkajian : ..........................................................................................................
Dx. Medis : ..........................................................................................................
No. Register : ..........................................................................................................

B. Proses Keperawatan

A. RiwayatKesehatan
1. KeluhanUtama :..........................................................................................................................................
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2. RiwayatPenyakitSekarang :
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 B. Data Fokus Dari HasilPengkajian

3. KondisiPasien :
DS : ................................................................................................................................................................
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4. DiagnosaKeperawatan :
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5. TujuanKhusus (Alasandilakukantindakan) :
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 INTERVENSI, IMPLEMENTASI & EVALUASI
ASUHAN KEPERAWATAN

NO. DIAGNOSA IMPLEMENTASI

SIKI SLKI EVALUASI
KEPERAWATAN JAM TINDAKAN