resume jiwa
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RESUME ASUHAN KEPERAWATAN JIWA
PADA PASIEN _________ DENGAN_______________________
TANGGAL __________________________
DI RUANG _________ RS JIWA PROPINSI BALI
OLEH :
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PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA
2012
Resume Asuhan Keperawatan Pada ...............................................
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A. Identitas Pasien
Nama : No RM :
Umur : Tgl MRS :
Jenis Kelamin : Dx Medis :
Alamat :
B. Keadaan Umum
Keadaan Umum :
TTV :
- TD =
- N =
- RR =
- T =
C. Riwayat Masuk RS
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D. Data Fokus
S : (Data Subjektif)
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O : (Data Objektif)
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A : (Diagnosa Keperawatan)
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P (rencana keperawatan pada hari itu diperlukan untuk mengatasi diagnosa point
A)
Hari / Tgl
No Dx
Rencana KeperawatanTujuan dan Kriteria
HasilIntervensi Rasional
I (Implementasi pada hari itu)
Hari / Tgl
No Dx
Jam Tindakan Keperawatan Respon Klien TTD
E (Evaluasi hari itu untuk masalah point A)
No Hari / Tgl No Dx Jam Evaluasi TTD
Mengetahui Denpasar, ......................... 2012
Pembimbing Mahasiswa
(....................................................) (......................................................)
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