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CATATAN PERKEMBANGAN KEPERAWATAN

NAMA : RUANGAN :
JENIS KELAMIN : NO. REGISTER :
UMUR : DX MEDIS :
TANGGAL/JAM SOAP KETERANGAN PARAF

DS : .........................................................................................................................
..................
............................................................................................................................
...............
DO : K/u ....................................................
Kesadaran : ....................................................
Vital Sign : TD......../..........mmHg ; Nadi ........x/mnt ; Suhu ........ oC ; RR
........x/mnt
BAB : frekwensi.................; Konsistensi cair/ampas/lunak/keras,
Warna Kuning/hitam/merah/hijau..................... ; Bau :...............................................
Bising Usus ............x/mnt ; Mukosa lembab/kering
..........................................................................................................................................
..........................................................................................................................................
A : Masalah belum teratasi/ Masalah Teratasi
P : Intervensi dilanjutkan/ganti/dihentikan............................................................
DS : .........................................................................................................................
..................
............................................................................................................................
...............
DO : K/u ....................................................
Kesadaran : ....................................................
Vital Sign : TD......../..........mmHg ; Nadi ........x/mnt ; Suhu ........ oC ; RR
........x/mnt
BAB : frekwensi.................; Konsistensi cair/ampas/lunak/keras,
Warna Kuning/hitam/merah/hijau..................... ; Bau :...............................................
Bising Usus ............x/mnt ; Mukosa lembab/kering
..........................................................................................................................................
..........................................................................................................................................
A : Masalah belum teratasi/ Masalah Teratasi
P : Intervensi dilanjutkan/ganti/dihentikan............................................................
DS : .........................................................................................................................
..................
............................................................................................................................
...............
DO : K/u ....................................................
Kesadaran : ....................................................
Vital Sign : TD......../..........mmHg ; Nadi ........x/mnt ; Suhu ........ oC ; RR
........x/mnt
BAB :frekwensi.................; Konsistensi cair/ampas/lunak/keras,
Warna Kuning/hitam/merah/hijau..................... ; Bau :...............................................
Bising Usus ............x/mnt ; Mukosa lembab/kering
..........................................................................................................................................
..........................................................................................................................................
A : Masalah belum teratasi/ Masalah Teratasi
P : Intervensi dilanjutkan/ganti/dihentikan............................................................
DS : .........................................................................................................................
..................
............................................................................................................................
...............
DO : K/u ....................................................
Kesadaran : ....................................................
Vital Sign : TD......../..........mmHg ; Nadi ........x/mnt ; Suhu ........ oC ; RR
........x/mnt
BAB : frekwensi.................; Konsistensi cair/ampas/lunak/keras,
Warna Kuning/hitam/merah/hijau..................... ; Bau :...............................................
Bising Usus ............x/mnt ; Mukosa lembab/kering
..........................................................................................................................................
..........................................................................................................................................
A : Masalah belum teratasi/ Masalah Teratasi
P : Intervensi dilanjutkan/ganti/dihentikan............................................................
DS : .........................................................................................................................
..................
............................................................................................................................
...............
DO : K/u ....................................................
Kesadaran : ....................................................
Vital Sign : TD......../..........mmHg ; Nadi ........x/mnt ; Suhu ........ oC ; RR
........x/mnt
BAB : frekwensi.................; Konsistensi cair/ampas/lunak/keras,
Warna Kuning/hitam/merah/hijau..................... ; Bau :...............................................
Bising Usus ............x/mnt ; Mukosa lembab/kering
..........................................................................................................................................
..........................................................................................................................................
A : Masalah belum teratasi/ Masalah Teratasi
P : Intervensi dilanjutkan/ganti/dihentikan............................................................
DS : .........................................................................................................................
..................
............................................................................................................................
...............
DO : K/u ....................................................
Kesadaran : ....................................................
Vital Sign : TD......../..........mmHg ; Nadi ........x/mnt ; Suhu ........ oC ; RR
........x/mnt
BAB : frekwensi.................; Konsistensi cair/ampas/lunak/keras,
Warna Kuning/hitam/merah/hijau..................... ; Bau :...............................................
Bising Usus ............x/mnt ; Mukosa lembab/kering
..........................................................................................................................................
..........................................................................................................................................
A : Masalah belum teratasi/ Masalah Teratasi
P : Intervensi dilanjutkan/ganti/dihentikan............................................................