FORMAT PENGKAJIAN RESUME KEPERAWATAN GAWAT DARURAT

Identitas Klien

Nama : ........................................................................................................................................
Usia : ........................................................................................................................................
Jenis Kelamin : ........................................................................................................................................
Agama : ........................................................................................................................................
Alamat : ........................................................................................................................................
Tanggal Masuk : ........................................................................................................................................
No. MR : ........................................................................................................................................
Diagnosa Medis : ........................................................................................................................................

Keluhan Utama : ........................................................................................................................................

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Resume : ........................................................................................................................................
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Pengkajian Primer :
Airway

Breathing

Circulation

Disability

Eksposure

Pengkajian Sekunder :
Riwayat kesehatan sekarang :
........................................................................................................................................
........................................................................................................................................
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Riwayat kesehatan lalu :
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Riwayat kesehatan keluarga :
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Pengkajian Head to Toe :
Kepala

Leher

Thorak

Abdomen

Ekstremitas

Integumen

Pemeriksaan Penunjang :
Radiologi
Lab

Pemeriksaan
lain

Terapi medis
 LAPORAN RESUME PASIEN UNIT GAWAT DARURAT
Nama : ……..…….……                     
Usia : ………...…........
Jenis Kelamin : L/P
No. MR : ………...…........
Diagnosa Medis : ………...…........

TGL/JAM SUBJEKTIF OBJEKTIF DIAGNOSA RENPRA IMPLEMENTASI EVALUATION

Tujuan : S:
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Kriteria Hasil : O:
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Intervensi :
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