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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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