Indentitas Pasien
Nama : ........................... No. RM : .........................
Umur : ........................... Tgl. MRS : .........................
Jenis kelamin : ........................... Dx. Medis : .........................
Alamat : ...........................
A. Data Fokus
S : .................................................................................................................................
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O : ...................................................................................................................................
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A : …………………………………………………………………………………….
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P : Rencana keperawatan pada hari itu diperlukan untuk mengatasi diagnosa pada point A
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I : Implementasi yang dilakukan pada hari itu
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O :
A :
P :
Mengetahui pembimbing Mahasiswa
Ns. I.A Agung Laksmi, S.Kep., M.Kep Anak Agung Sri Widari
NIK : 17.01.0107 Nim : C2118071
LEMBAR PENGESAHAN
Diajukan Oleh:
Perseptor Perseptor
Klinik Akademik
Ns. Sang Putu Artika, S.Kep Ns. I Made Dwie Pradnya Susila, S.Kep.,
Nip : 19670227 198801 002 M.Kes
NIK 12.10.0057
Mengetahui
Program Lintas Jalur Prodi S1 Keperawatan
Ka.Prodi