FORMAT RESUME KEPERAWATAN MEDIKAL

BEDAH
Tanggal MRS : Jam Masuk :
Tanggal Pengkajian : No. RM :
Jam Pengkajian : Diagnosa Masuk :

IDENTITAS
1. Nama Pasien :
2. Umur :
3. Suku/ Bangsa :
4. Agama :
5. Pendidikan :
6. Pekerjaan :
7. Alamat :
8. Sumber Biaya :

KELUHAN UTAMA
Keluhan utama :
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RIWAYAT PENYAKIT SEKARANG

Riwayat Penyakit Sekarang :
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OBSERVASI DAN PEMERIKSAAN FISIK
Tanda tanda vital
S: N: T: RR :
Kesadaran Compos Mentis Apatis Somnolen Sopor Koma
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 ANALISIS DATA

Hari/
MASALAH
Tgl/ DATA ETIOLOGI
KEPERAWATAN
Jam

DIAGNOSA KEPERAWATAN :
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 RENCANA INTERVENSI

Hari/ NOC NIC

No. DIAGNOSA KEPERAWATAN (Nursing Outcome Classification) (Nursing Intervention Classification)
Tgl/ Jam
 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/
No.
Tgl/ Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf
Dx
Shift