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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