RESUME KEPERAWATAN

A. Identitas Pasien
Identitas bayi Identitas Orang tua
Nama : Nama Ayah :
No. register : Nama Ibu :
Tanggal lahir : Pekerjaan Ayah :
Umur : Pekerjaan Ibu :
Jenis kelamin : Agama :
Tgl MRS : Suku Bangsa :
Diagnose Medis : Alamat :

B. Deskripsi kesehatan pasien

S:
- Keluhan Utama yang dirasakan pasien
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- Riwayat penyakit pasien
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O : Hasil pemeriksaan fisik (Data Fokus)

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A : Diagnosa Keperawatan
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P : Rencana Keperawatan
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I : Tindakan yang dilakukan
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E : Evaluasi dari tindakan dan perkembangan klien
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