RESUME EVALUASI PRAKTEK KEPERAWATAN DASAR PROFESI

Tanggal : .................................

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

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4. Riwayat Penyakit Dahulu

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5. Riwayat Penyakit Keluarga

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 6. Diagnosa 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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Analisa Data

No Data Subyektif Data Obyektif (Masalah Keperawatan)

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 II. DIAGNOSA KEPERAWATAN

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III. PERENCANAAN
A. Prioritas Masalah Keperawatan (Berdasarkan……………………………………………..)
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 B. Rencana Keperawatan

Rencana Keperawatan Pada Pasien....….……Dengan…........…...........……

Di Ruang……….…..RSU…………………..........Tanggal……….………

No Hari/Tgl/ Diagnosa Rencana Tujuan Rencana Tindakan Rasional

Jam Keperawatan
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 IV. PELAKSANAAN
Pelaksanaan Keperawatan Pada Pasien..…………Dengan….........................…
Di Ruang….............RSU……………..............Tanggal……………....…….
No Hari/Tgl/Jam No. Diagnosa Tindakan Keperawatan
Keperawatan
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Evaluasi Respon Paraf
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V. EVALUASI

Evaluasi Keperawatan Pada Pasien.……………….Dengan……….................................

Di Ruang……………..RSU……………...........Tanggal………..……........…

No Hari/Tgl/Jam Diagnosa Keperawatan Evaluasi

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