Resume Poli

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FORMAT RESUME POLIKLINIK

Nama Mahasiswa : ...............................................................................

Npm : ...............................................................................
Tanggal Pengkajian : ...............................................................................

A. Identitas Pasien
1. Nama : ...............................................................................
2. Umur : ...............................................................................
3. Jenis Kelamin : ...............................................................................
4. Nama Orang tua : ...............................................................................
5. Alamat : ...............................................................................
6. Diagnosa medis saat dirawat : ...............................................................................
7. Hari dan tanggal perawatan : ...............................................................................
8. Diijinkan pulang tanggal : ...............................................................................
9. Sekarang kontrol ke : ...............................................................................

B. Keluhan Utama
........................................................................................................................................................
........................................................................................................................................................
.........................................................................................................................................

C. Hasil pengkajian yang mendukung

1. Pemeriksaan fisik (diisi yang mendukung ke masalah keperawatan yang muncul saja)
................................................................................................................................................
......................................................................................................................................
2. Pemeriksaan Penunjang
................................................................................................................................................
......................................................................................................................................

D. Analisa Data

NO DATA MASALAH ETIOLOGI

E. Rencana Keperawatan

DIAGNOSA TUJUAN INTERVENSI RASIONAL

F. Catatan Perkembangan (Evaluasi)

DIAGNOSA IMPLEMENTASI PARAF EVALUASI

Pembimbing Klinik, Pembimbing Akademik,

__________________ ______________________

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