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  • Lampiran 8. Format Resume Klien

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    2 views8 pages

    Lampiran 8. Format Resume Klien

    Uploaded by

    AdiSetiawan

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 8

    Resume Klien

    LAPORAN KLIEN RESUME

    I. IDENTITAS KLIEN
    Nama : …………………………………………………………………
    Umur : …………………………………………………………………
    Tanggal Pengkajian : …………………………………………………………………
    Tanggal MRS : …………………………………………………………………
    No Register : …………………………………………………………………
    Informan : …………………………………………………………………
    Pendidikan : …………………………………………………………………
    Pekerjaan : …………………………………………………………………
    Status Perkawinan : …………………………………………………………………

    II. PENGKAJIAN
    A. Alasan Masuk (Keluhan Utama)
    …………………………………………………………………………………………..
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    B. Riwayat Penyakit dan Data Klien


    …………………………………………………………………………………………..
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    C. Sistem Kategori Klien


    …………………………………………………………………………………………...

    III. MASALAH/DIAGNOSA KEPERAWATAN


    Data Maladaptif Masalah/Diagnosa Keperawatan
    IV. ENCANA ASUHAN KEPERAWATAN
    Diagnosa Perencanaan
    Hari/Tanggal
    Keperawatan Tujuan Kriteria Hasil Intervensi
    V. IMPLEMENTASI
    Hari/Tanggal Diagnosa Keperawatan Implementasi
    VI. EVALUASI (SOAP)
    Hari/Tanggal Diagnosa Keperawatan Evaluasi (SOAP)

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