PRODI SARJANA ILMU KEPERAWATAN

FAKULTAS ILMU KESEHATAN

UNIVERSITAS HAFSHAWATY ZAINUL HASAN

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

NIM : …………………………………………………

FORMAT RESUME KEPERAWATAN

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 :
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

RIWAYAT PENYAKIT SEKARANG

Riwayat Penyakit Sekarang :
………………………………………………………………………………..........................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
OBSERVASI DAN PEMERIKSAAN FISIK
Tanda tanda vital
S: N: T: RR :
Kesadaran Compos Mentis Apatis Somnolen Sopor Koma
………………………………………………………………………………..........................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
………………………………………………………………………………..........................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
DIAGNOSA KEPERAWATAN :
1. ……………………………………………………………………………….....................................................................
2. ……………………………………………………………………………….....................................................................
3. ……………………………………………………………………………….....................................................................
4. ……………………………………………………………………………….....................................................................
5. ……………………………………………………………………………….....................................................................

INTERVENSI KEPERAWATAN
………………………………………………………………………………..........................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
………………………………………………………………………………..........................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................

IMPLEMENTASI KEPERAWATAN
………………………………………………………………………………..........................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
………………………………………………………………………………..........................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................

EVALUASI KEPERAWATAN
………………………………………………………………………………..........................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
………………………………………………………………………………..........................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................
..................................................................................................................................................................................................
……………………………………………………………………………………………………………..............................