Tanggal..............................
A. Identitas Pasien
Nama
No RM
Umur
Tgl MRS :
Jenis Kelamin :
Dx Medis :
Alamat
B. Data Fokus
S : <data Subjektif pasien>
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O : <data Objektif pasien>
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A : <Diagnosa Keperawatan yang muncul>
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P : <rencana keperawatan >
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I : (Implementasi>
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E : <Evaluasi>
S : .......................................................................................................
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O : .......................................................................................................
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A : .......................................................................................................
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P : .......................................................................................................
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Mengetahui
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Pembimbing
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