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LAPORAN RESUME ASUHAN KEPERAWATAN Nama Mahasiswa NIM Tempat Praktek Tanggal

: ………………………… : ………………………… : ………………………… : …………………………

A. Identitas Pasien Nama : ……………………….... Umur : ………………………… Jenis Kelamin : ………………………… Alamat : ………………………… No RM : ………………………… Tgl MRS : ………………………… Dx Medis : ………………………… B. Riwayat Penyakit sekarang …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. C. Data Fokus S (data Subjektif pasien) ………………………………………………………………………………………….. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. O (data Objektif pasien) ………………………………………………………………………………………...... …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. A (diagnose keperawatan yang muncul) ………………………………………………………………………………………….. …………………………………………………………………………………………. …………………………………………………………………………………………. ………………………………………………………………………………………….

P (rencana keperawatan pada hari itu yang diperlukan untuk mengatasi diagnose pada point A) kolom ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………………………

I (implementasi yang dilakukan pada saat itu) kolom ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………………………

E (evaluasi hari itu untuk masalah pada point A) kolom  S : …………………………………………………………………………………..  O : …………………………………………………………………………………..  A : ………………………………………………………………………………….  P : …………………………………………………………………………………..

Mengetahui Pembimbing

Denpasar,………20..

(………………………….)

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