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  • Format Resume: I. Biodata

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    Nirla Puspitasari Arifin
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    This document outlines the sections and headings that should be included in a patient's medical resume. The sections are: I. Biodata - Contains personal information about the patient such as name, gender, age, marital status, occupation, religion, highest level of education, address, and dates. II. Health Assessment Data - Contains sections for the patient's chief complaint, current and past medical history, family medical history, daily activity patterns, physical examination findings, psychosocial data, spiritual data, and results of any medical tests. III. Nursing Diagnosis - Lists the nursing diagnoses based on the assessment data.

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    Format Resume

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    This document outlines the sections and headings that should be included in a patient's medical resume. The sections are: I. Biodata - Contains personal information about the patient such as name, gender, age, marital status, occupation, religion, highest level of education, address, and dates. II. Health Assessment Data - Contains sections for the patient's chief complaint, current and past medical history, family medical history, daily activity patterns, physical examination findings, psychosocial data, spiritual data, and results of any medical tests. III. Nursing Diagnosis - Lists the nursing diagnoses based on the assessment data.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    10 views2 pages

    Format Resume: I. Biodata

    Uploaded by

    Nirla Puspitasari Arifin
    This document outlines the sections and headings that should be included in a patient's medical resume. The sections are: I. Biodata - Contains personal information about the patient such as name, gender, age, marital status, occupation, religion, highest level of education, address, and dates. II. Health Assessment Data - Contains sections for the patient's chief complaint, current and past medical history, family medical history, daily activity patterns, physical examination findings, psychosocial data, spiritual data, and results of any medical tests. III. Nursing Diagnosis - Lists the nursing diagnoses based on the assessment data.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 2

    FORMAT RESUME

    I. BIODATA

    Nama : …………………………………………………………………
    Jenis kelamin : …………………………………………………………………
    Umur : …………………………………………………………………
    Status Perkawinan : …………………………………………………………………
    Pekerjaan : …………………………………………………………………
    Agama : …………………………………………………………………
    Pendidikan Terakhir : …………………………………………………………………
    Alamat : …………………………………………………………………
    Tanggal MRS : …………………………………………………………………
    Tanggal Pengkajian : …………………………………………………………………

    II. PENGKAJIAN DATA


    RIWAYAT KESEHATAN PASIEN
    1. Keluhan utama
    …………………………………………………………………………………………………………
    …………………………………………………………………………………………………………
    …………………………………………………

    2. Riwayat Kesehatan Sekarang


    …………………………………………………………………………………………………………
    …………………………………………………………………………………………………………
    …………………………………………………

    3. Riwayat kesehatan yang lalu


    …………………………………………………………………………………………………………
    …………………………………………………………………………………………………………
    …………………………………………………

    4. Riwayat kesehatan keluarga


    …………………………………………………………………………………………………………
    …………………………………………………………………………………………………………
    …………………………………………………

    POLA AKTIFITAS SEHARI-HARI (Data Fokus)


    …………………………………………………………………………………………………………
    …………………………………………………………………………………………………………
    …………………………………………………………………

    PEMERIKSAAN FISIK (Data Fokus)


    …………………………………………………………………………………………………………
    …………………………………………………………………………………………………………
    …………………………………………………………………

    DATA PSIKOSOSIAL (Data Fokus)


    …………………………………………………………………………………………………………
    …………………………………………………………………………………………………………
    …………………………………………………………………
    DATA SPIRITUAL (Data Fokus)
    …………………………………………………………………………………………………………
    …………………………………………………………………………………………………………
    …………………………………………………………………

    PEMERIKSAAN PENUNJANG (Data Fokus)


    …………………………………………………………………………………………………………
    …………………………………………………………………………………………………………
    …………………………………………………………………

    III. DIAGNOSA KEPERAWATAN


    1. …………………………………………………………………
    2. …………………………………………………………………
    3. …………………………………………………………………

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