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KALA I

A. DATA FOKUS KALA I

DATA FOKUS ANALISIS MASALAH


B. ANALISA DATA KALA I
DATA FOKUS ANALISIS MASALAH
Diagnosa keperawatan berdasarkan prioritas :
1. ..............................................................................................
2. ..............................................................................................
3. ..............................................................................................
4. ..............................................................................................
5. ..............................................................................................

C. RENCANA KEPERAWATAN KALA I


N Tgl / jam Nomor Rencana Keperawatan
o Diagnosa Tujuan Intervensi Rasional
D. IMPLEMENTASI KALA I

Tgl/Jam No. Implementasi Respon Paraf/Nama


Dx
E. EVALUASI KALA I

Tgl/Jam No Evaluasi Hasil Paraf


Dx

KALA II
A. DATA FOKUS KALA II
B. ANALISA DATA KALA II
DATA FOKUS ANALISIS MASALAH
Diagnosa keperawatan berdasarkan prioritas :
1. ...........................................................................................
2. ...........................................................................................
3. ...........................................................................................
4. ...........................................................................................
5. ...........................................................................................
C. RENCANA KEPERAWATAN KALA II
No Tgl / jam Nom Rencana Keperawatan
or Tujuan Intervensi Rasional
Diag
nosa
D. IMPLEMENTASI KALA II
Tgl/Jam No. Implementasi Respon Paraf/Nama
Dx
E. EVALUASI KALA II
Tgl/Jam No Evaluasi Hasil Paraf
Dx

KALA III
A. DATA FOKUS KALA III
B. ANALISA DATA KALA III

DATA FOKUS ANALISIS MASALAH


Diagnosa keperawatan berdasarkan prioritas :
1. ...........................................................................................
2. ...........................................................................................
3. ...........................................................................................
4. ...........................................................................................
5. ...........................................................................................

C. RENCANA KEPERAWATAN KALA III

No Tgl / jam Nom Rencana Keperawatan


or Tujuan Intervensi Rasional
Dx.
D. IMPLEMENTASI KALA III

Tgl/Jam No. Implementasi Respon Paraf/Nama


Dx
E. EVALUASI KALA III

Tgl/Jam No Evaluasi Hasil Paraf


Dx

KALA IV
A. DATA FOKUS KALA IV
B. ANALISA DATA KALA IV
DATA FOKUS ANALISIS MASALAH
Diagnosa keperawatan berdasarkan prioritas :
1. ...........................................................................................
2. ...........................................................................................
3. ...........................................................................................
4. ...........................................................................................
5. ...........................................................................................
C. RENCANA KEPERAWATAN KALA IV
No Tgl / jam Nom Rencana Keperawatan
or Tujuan Intervensi Rasional
Dx.
D. IMPLEMENTASI KALA IV
Tgl/Jam No. Implementasi Respon Paraf/Nama
Dx
E. EVALUASI KALA IV
Tgl/Jam No Evaluasi Hasil Paraf
Dx
Denpasar, .20..
Mengetahui
Pembimbing Klinik/ CI Mahasiswa

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NIP: NIM:

Clinical Teacher/CT

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NIP: