PROGRAM STUDI PENDIDIKAN NERS

STIKES SURYA MITRA HUSADA KEDIRI

PROGRAM PENDIDIKAN PROFESI NERS
ALAMAT : JLN. Manila No. 37 Sumberece Kota Kediri Telp. (0354) 7009713 Fax. (0354) 695130

Nama Mahasiswa : ...

NIM :

FORMAT RESUME KEPERAWATAN MEDIKAL BEDAH

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
..........................................................................
..............................
..................................................................................................................................................................................................
..............................
..................................................................................................................................................................................................
..............................
..................................................................................................................................................................................................
..........................................................................
..............................
..................................................................................................................................................................................................
..............................

STIKes Surya Mitra Husada Kediri

 ANALISIS DATA

Hari/
MASALAH
Tgl/ DATA ETIOLOGI
KEPERAWATAN
Jam

DIAGNOSA KEPERAWATAN :
..........................................................................
..............................
..................................................................................................................................................................................................
..............................
..................................................................................................................................................................................................
..............................
..................................................................................................................................................................................................

STIKes Surya Mitra Husada Kediri

 RENCANA INTERVENSI

Hari/ NOC NIC

No. DIAGNOSA KEPERAWATAN
Tgl/ Jam (Nursing Outcome Classification) (Nursing Intervention Classification)

STIKes Surya Mitra Husada Kediri

 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/
No.
Tgl/ Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf
Dx
Shift

STIKes Surya Mitra Husada Kediri

STIKes Surya Mitra Husada Kediri