Anda di halaman 1dari 3

FORMAT

WAWANCARA TERSTRUKTUR
Inisial klien
: ........................................................
Status interaksi perawat kien
: ........................................................
Lingkungan
: ........................................................
Deskripsi Klien
: ........................................................
Tujuan (Berorientasi pada klien)
: .......................................................
KOMUNIKASI VERBAL

Nama peserta
Tanggal
Jam
Ruang

: ......................................................
: ......................................................
: ......................................................
: ......................................................

KAMUNIKASI NON VERBAL

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ..........................................................................................................

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ..........................................................................................................

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ..........................................................................................................

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ...........................................................................................................

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ...........................................................................................................

KOMUNIKASI VERBAL

KAMUNIKASI NON VERBAL

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ..........................................................................................................

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ..........................................................................................................

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ..........................................................................................................

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ...........................................................................................................

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ...........................................................................................................

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ...........................................................................................................

KOMUNIKASI VERBAL

KAMUNIKASI NON VERBAL

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ..........................................................................................................

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ..........................................................................................................

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ..........................................................................................................

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ...........................................................................................................

P: ............................................................................................................................................ P: ...........................................................................................................
K: ...........................................................................................................................................

K: ...........................................................................................................
Malang,.................................................
Perawat yang mengkaji

(............................................................)