PROGRAM STUDI PENDIDIKAN NERS

INSTITUT ILMU KESEHATAN STRADA INDONESIA

Jln. Manila No. 37 Sumberece Kota Kediri Telp. (0354) 7009713 Fax. (0354) 695130

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

NIM : …………………………………………………

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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IIK STRADA INDONESIA

www.iik-strada.ac.id
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ANALISIS DATA

Hari/
MASALAH
Tgl/ DATA ETIOLOGI
KEPERAWATAN
Jam

DIAGNOSA KEPERAWATAN :
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IIK STRADA INDONESIA

www.iik-strada.ac.id
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IIK STRADA INDONESIA

www.iik-strada.ac.id
 RENCANA INTERVENSI
Hari/ NOC
No. DIAGNOSA KEPERAWATAN
Tgl/ Jam (Nursing Outcome Classification) (N

IIK STRADA INDONESIA

www.iik-strada.ac.id
 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/
No.
Tgl/ Jam Implementasi Paraf Jam
Dx
Shift

IIK STRADA INDONESIA

www.iik-strada.ac.id
IIK STRADA INDONESIA
www.iik-strada.ac.id