Nama Mahasiswa : ………………………………………………...

NIM : …………………………………………………

RESUME ASUHAN KEPERAWATAN

Tanggal MRS : Jam Masuk :

Tanggal Pengkajian : No. RM : Jam
Pengkajian : Diagnosa Masuk :

IDENTITAS
1. Nama Pasien :
2. Umur :
3. Suku/ Bangsa :
4. Agama :
5. Pendidikan :
6. Pekerjaan :
7. Alamat :

KELUHAN UTAMA
Keluhan utama :
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RIWAYAT PENYAKIT SEKARANG

Riwayat Penyakit Sekarang :
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OBSERVASI DAN PEMERIKSAAN FISIK
Tanda tanda vital
S: N: T: RR :

Kesadaran Compos Mentis Apatis Somnolen Sopor Koma

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 ANALISIS DATA

Hari/
Tgl/ Data Etiologi Masalah Keperawatan
Jam

DIAGNOSA KEPERAWATAN :

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 RENCANA INTERVENSI

Hari/
No. Diagnosa Keperawatan Kriteria hasil Intervensi Keperawatan
Tgl/ Jam
 IMPLEMENTASI DAN EVALUASI
KEPERAWATAN

Hari/
No.
Tgl/ Jam Implementasi Paraf
Dx
Shift