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FORMAT RESUME

Tanggal Pengkajian

Jam

Tanggal MRS

No. Reg

Ruang

Diagnosa masuk

A. IDENTITAS KLIEN
Nama

Penanggung Jawab Biaya

Usia

Nama

Jenis Kelamin :

Alamat

Suku

Hub. Keluarga

Agama

Telepon

Pendidikan

Pekerjaan

Alamat

B. RIWAYAT PENYAKIT SEKARANG


1) Keluhan utama

2) Riwayat Penyakit Sekarang :

C. RIWAYAT PENYAKIT DAHULU


1) Riwayat Penyakit Kronik dan menular

ya, jenis :............................................

tidak

2) Riwayat Penyakit Alergi

ya, jenis :............................................

tidak

3) Riwayat Operasi

ya, jenis :............................................

tidak

D. RIWAYAT PENYAKIT KELUARGA


Ya, sebutkan..................................................

tidak

E. PSIKOSOSIAL
1) Sosial / Interaksi

:.......................................................................

2) Konsep Diri

:.......................................................................

3) Spiritual

:.......................................................................

Dx. Keperawatan
Intervensi
Implementasi
Evaluasi (SOAP)
Tujuan dan Kriteria Hasil
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No

Tanggal

Data (DO/DS)

LEMBAR PENGESAHAN

Nama :
Nim

Judul :

Lamongan,

2013

Mahasiswa

(________________________
)
Mengtahui

Pembimbing Klinik

Pembimbing Akademik

(_______________________
)

(______________________)