RESUME EVALUASI PRAKTEK KEPERAWATAN DASAR PROFESI

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I. PENGKAJIAN
A. Identitas Pasien
Nama : ....................................... No RM : .................................
Umur : ....................................... Tanggal MRS : .................................
Jenis : .......................................
Kelamin
Alamat : .......................................

B. Riway at Kesehatan
1. Keluhan utama saat masuk RS
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2. Keluhan utama saat pengkajian

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3. Riwayat penyakit sekarang

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4. Riwayat penyakit dahulu

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 5. Riwayat penyakit keluarga
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6. Dx Medis dan terapi saat pengkajian

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C. Pola kebiasaan pasien (tulis yang bermasalah saja)

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D. Pemeriksaan fisik (tulis yang bermasalah saja)

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 E. Pemeriksaan Penunjang (Penunjang Diagnosa)
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F. Analisa Data
No Data Subyektif Data Obyektif (MasalahKeperawatan)

II. DIAGNOSA KEPERAWATAN

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III. PERENCANAAN
A. Prioritas Masalah Keperawatan
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B. Rencana Keperawatan
No Hari/Tgl/Jam Dx. Rencana Rencana Rasional
Keperawatan Tujuan Tindakan
IV. PELAKSANAAN
No Hari/Tgl/Jam No. Diagnosa Tindakan Evaluasi Paraf
Keperawatan Keperawatan Respon
V. EVALUASI
No Hari/Tgl/Jam Diagnosa Evaluasi
Keperawatan
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