RESUME

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Tanggal pengkajian : ...........................................................................
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I. IDENTITAS KLIEN
Nama : ..................................(L/P)
Umur : ..........................................
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Status : ..........................................
Pekerjaan : ..........................................
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II. ALASAN MASUK

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III. RIWAYAT PENYAKIT SEKARANG (FAKTOR PRESIPITASI)

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IV. RIWAYAT PENYAKIT DAHULU (FAKTOR PREDISPOSISI)

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V. STATUS MENTAL
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VI. ASPEK MEDIS
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VII. ANALISIS DATA

No DATA DIAGNOSIS KEPERAWATAN

VIII. DAFTAR DIAGNOSIS KEPERAWATAN

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RENCANA TINDAKAN KEPERAWATAN

No Diagnosis Luaran dan Intervensi OTEK

Kriteria Hasil
 CATATAN PERKEMBANGAN KEPERAWATAN

Hari, tgl Tindakan Evaluasi

Jam