Resume Keperawatan Rawat Inap Baru

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RESUME KEPERAWATAN RAWAT INAP BARU

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KLINIK PRATAMA AVICENNA

Dk. Pengkol RT 11, Kel. Pengkol, Tanon, Sragen

Telp: 081 326 721 136
Email: klinikavicenna4@gmail.com

RESUME MEDIS
1. IDENTITAS PASIEN
 Nama : ……………………………………………………………….
 Nomor Kartu : ……………………………………………………………….
 Umur : ……………………………………………………………….
 Alamat :
……………………………………………………………….
 No Hp :
……………………………………………………………….
 Tanggal / jam masuk :
……………………………………………………………….
 Tanggal / jam keluar : ……………………………………………………………….

2. ALASAN MASUK KLINIK

……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
3. DIAGNOSA AWAL
……………………………………………………………………………………………
……………………………………………………………………………………………

4. DIAGNOSA AKHIR
……………………………………………………………………………………………
……………………………………………………………………………………………

5. PEMERIKSAAN PENUNJANG
……………………………………………………………………………………………
6. TERAPI YANG DIBERIKAN

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

7. TINDAKAN LANJUTAN ( lingkari salah satu )

a. Sembuh c. Dirujuk ke.......................

b. APS d. Meninggal

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