Format Resume Keperawatan

Nama Mahasiswa :…………………………
STIKes Hafshawaty
NIM : ………………………..
Pesantren Zainul Hasan Ruangan : ……………………….
FORMAT RESUME KEPERAWATAN

PRAKTIK KLINIK KEPERAWATAN
Nama : ……………………………….. No. Register : ………………………………..

Umur ( Usia ) : ……………………………….. Suku Bangsa : ………………………………..
Jenis Kelamin : ……………………………….. Tgl. MRS : ………………………………..
Agama : ……………………………….. Tgl. KRS : ………………………………..
Pekerjaan : ……………………………….. Dx. Medis : ………………………………..
Alamat : ……………………………….. Tgl. Pengkajian : ………………………………..
ANAMNESE
Sumber Informasi : □ Klien □ Keluarga
□ Lain-lain : …………………………………………………………………………………………………………..
I. IDENTITAS KLIEN
Nama :……………………………………………………………………..
Umur :…………………………………………………………………….
Jenis Kelamin :…………………………………………………………………….
Suku / Bangsa :………………………………………………………………………
AgamaPekerjaan :………………………………………………………………………
Pendidikan :………………………………………………………………………
Alamat :………………………………………………………………………
No. Register :…………………………………………………………………….
Tanggal MRS :………………………………………………..............................
Diagnosa Medis :………………………………………………..............................
Sumber Informasi :………………………………………………..............................
Penanggung : Askes / Astek / Jamsostek / JPS / Sendiri
II. KELUHAN UTAMA

……………………………………………………………………………………………………………….................……………..
………………………………………………………………………………………………………………………..................…….
III. RIWAYAT PENYAKIT SEKARANG

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Format Pengkajian Resume PKK STIKes Hafsahwaty Pesantren Zainul Hasan 1

IV. PEMERIKSAAN FISIK FOKUS PADA KASUS
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.
V. PEMERIKSAAN DIAGNOSTIK DAN PENATALAKSANAAN
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VI. ANALISA DATA

…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………….
VII. DIAGNOSA KEPERAWATAN (Sesuai kasus KDM)

1. ………………………………………
VIII. INTERVENSI KEPERAWATAN/RENCANA TINDAKAN KEPERAWATAN

Diagnosa Keperawatan 1
............................................................................................................................................................................................
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..
............................................................................................................................................................................................
............................................................................................................................................................................................
............................................................................................................................................................................................
.
IX. IMPLEMENTASI KEPERAWATAN
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..
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.....................................................................................................................................................
X. EVALUASI (tiap Diagnosa Keperawatan)

S : .....................................................................................................................................................................................
O : ....................................................................................................................................................................................
A : ....................................................................................................................................................................................
P : ....................................................................................................................................................................................
Probolinggo, ........................ 20.....

Mahasiswa,
----------------------------------------
Format Pengkajian Resume PKK STIKes Hafsahwaty Pesantren Zainul Hasan 2

Format Resume Keperawatan

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Format Resume Keperawatan

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Nama Mahasiswa :…………………………

FORMAT RESUME KEPERAWATAN

Nama : ……………………………….. No. Register : ………………………………..

II. KELUHAN UTAMA

III. RIWAYAT PENYAKIT SEKARANG

Format Pengkajian Resume PKK STIKes Hafsahwaty Pesantren Zainul Hasan 1

VI. ANALISA DATA

VII. DIAGNOSA KEPERAWATAN (Sesuai kasus KDM)

VIII. INTERVENSI KEPERAWATAN/RENCANA TINDAKAN KEPERAWATAN

X. EVALUASI (tiap Diagnosa Keperawatan)

Probolinggo, ........................ 20.....

Format Pengkajian Resume PKK STIKes Hafsahwaty Pesantren Zainul Hasan 2

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