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ASUHAN KEPERAWATAN

POLIKLINIK JIWA
A. Identitas Klien
1. Nama : ...............................................................
2. No Register : ...............................................................
3. Umur : ...............................................................
4. Jenis Kelamin : ...............................................................
5. Alamat : ...............................................................
6. Dx Medis : axis I ...............................................................
axis II ...............................................................
axis III ..............................................................
axis IV ..............................................................
axis V ...............................................................
B. Identitas Penanggung Jawab
1. Nama : ...............................................................
2. Hub dengan klien: ...............................................................
3. Alamat : ...............................................................

C. Pengkajian
Hari /tanggal : ...............................................................
Tempat : ...............................................................
Sumber Data : ...............................................................

D. Riwayat Penyakit Dahulu


Riwayat penyakit sebelum
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Riwayat penyakit sesudah
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E. Genogram

F. Terapi
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G. Analisa Data
Data Masalah Keperawatan
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H. Diagnosa Keperawatan
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I. Rencana Intervensi, Implementasi, Evaluasi
No/
Intervensi Implementasi Evaluasi (SOAP)
Tgl
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