Format resume KMB - Ners STRADA
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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 Tanggal Pengkajian Jam Pengkajian IDENTITAS 1. Nama Pasien 2. Umur 3. Suku/ Bangsa 4. Agama 5. Pendidikan 6. Pekerjaan 7. Alamat 8. Sumber Biaya : : : Jam Masuk : No. RM : Diagnosa Masuk : : : : : : : : : 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/ Tgl/ Jam DATA ETIOLOGI MASALAH KEPERAWATAN DIAGNOSA KEPERAWATAN : ……………………………………………………………………………….......................................................................... …………………………………………………………………………………………………………….............................. .................................................................................................................................................................................................. …………………………………………………………………………………………………………….............................. .................................................................................................................................................................................................. …………………………………………………………………………………………………………….............................. .................................................................................................................................................................................................. STIKes Surya Mitra Husada Kediri RENCANA INTERVENSI No. Hari/ Tgl/ Jam DIAGNOSA KEPERAWATAN NOC (Nursing Outcome Classification) NIC (Nursing Intervention Classification) STIKes Surya Mitra Husada Kediri IMPLEMENTASI DAN EVALUASI KEPERAWATAN Hari/ Tgl/ Shift No. Dx Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf STIKes Surya Mitra Husada Kediri STIKes Surya Mitra Husada Kediri