FORMAT LAPORAN

RESUME KEPERAWATAN JIWA

1. PENGKAJIAN
A. IDENTITAS KLIEN
Nama (Inisial) :
L/P :
Umur :
Alamat :
Pendidikan :
Agama :
No. RM :
Tgl Pengkajian :

B. ALASAN MASUK
.......................................................................................................................................
.......................................................................................................................................
........................................................................................................................
C. PEMERIKSAAN FISIK
Keadaan umum :
TD :
Nadi :
Respirasi :
Suhu :
Keluhan fisik :
D. DATA FOKUS
DATA SUBYEKTIF DATA OBYEKTIF
E. ANALISA DATA

No DATA ETIOLOGI PROBLEM

1. Subyektif
.

Obyektif

2. Subyektif
.

Obyektif
F. DAFTAR DIAGNOSA KEPERAWATAN (PRIORITAS)
1. ............................................................................................................................
2. ............................................................................................................................

G. RENCANA INTERVENSI KEPERAWATAN

NO DIAGNOSA NOC NIC

TGL/JAM KEPERAWATAN
H. IMPLEMENTASI DAN EVALUASI

NO IMPLEMENTASI EVALUASI FORMATIF EVALUASI SUMATIF

TGL/JAM