LAPORAN HARIAN

KEPERAWATAN JIWA

Nama Mahasiswa :

Tempat Praktik :

Waktu Praktik :

Identitas klien

Nama : ............................................................................

Umur : ............................................................................

Jenis Kelamin : ............................................................................

Status Perkawinan : ............................................................................

Suku : ............................................................................

Agama : ............................................................................

Alamat : ............................................................................

Pendidikan : ............................................................................

Pekerjaan : ............................................................................

Lama Bekerja : ............................................................................

Diagnosa Medis : ............................................................................

Tanggal masuk RS : ............................................................................

Tanggal pengkajian awal : ............................................................................

Sumber informasi : ............................................................................

a. Riwayat Penyakit

Keluhan utama MRS

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Riwayat penyakit sekarang :

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Riwayat penyakit dahulu

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Pemeriksaan fisik

Tanda-tanda vital :

Suhu : .....................................................................................................................................

Nadi : .....................................................................................................................................

Pernafasan : ...........................................................................................................................

Tekanan darah : .....................................................................................................................

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Terapi yang diberikan :

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Diagnosa keperawatan :

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Tindakan keperawatan :

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Evaluasi :

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