RESUME EVALUASI PRAKTEK KEPERAWATAN DASAR PROFESI

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I. PENGKAJIAN
A. Identitas Pasien
Nama : ....................................... No RM : .................................

Umur : ....................................... Tanggal MRS : .................................

Jenis : .......................................

Kelamin
Alamat : .......................................

B. Riwayat Kesehatan
1. Keluhan utama saat masuk RS.
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2. Keluhan utama saat pengkajian
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3. Riwayat penyakit sekarang (dari awal timbul penyakit s/d dx medis, terapi saat
pengkajian)
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4. Riwayat penyakit dahulu
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5. Riwayat penyakit keluarga
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 6. Dx Medis dan terapi saat pengkajian
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C. Pola kebiasaan pasien (tulis yang bermasalah saja)
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D. Pemeriksaan fisik (tulis yang bermasalah saja)
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E. Pemeriksaan penunjang (Penunjang Diagnosa)
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F. Analisa Data
No Data Subyektif Data Obyektif (Masalah Keperawatan)
II. DIAGNOSA KEPERAWATAN
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III. PERENCANAAN
A. Prioritas Masalah Keperawatan
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B. Rencana Keperawatan
No Hari/Tgl/Jam Dx. Rencana Rencana Rasional
Keperawatan Tujuan Tindakan
IV. PELAKSANAAN
No Hari/Tgl/Jam No. Diagnosa Tindakan Evaluasi Paraf
Keperawatan Keperawatan Respon
V. EVALUASI
No Hari/Tgl/Jam Diagnosa Keperawatan Evaluasi

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