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ANALISA DATA

NAMA PASIEN : ……………….


NO.REKAM MEDIK: : ………………..
RUANG RAWAT : ………………………….
UMUR : ………………………….

TGL DATA FOKUS ETIOLOGI MASALAH


DIAGNOSA KEPERAWATAN

NAMA PASIEN : ……………….


NO.REKAM MEDIK: : ………………..
RUANG RAWAT : ………………………….
UMUR : ………………………….

TGL.
NO TGL.
MASALAH/DIAGNOSA TERATASI
DX. DITEMUKAN TTD
FORMAT
ANALISA PROSES INTERAKSI

Inisial klien : ........................................... Nama Mahasiswa : ...................................


Status interaksi perawat – kien : ........................................... Tanggal : ...................................
Lingkungan : ........................................... Jam : ..................................
Deskripsi Klien : ................................. Bangsal : ..................................
Tujuan (Berorientasi pada klien): ...............................

KOMUNIKASI KAMUNIKASI NON ANALISA BERPUSAT ANALISA BERPUSAT RASIONAL


VERBAL VERBAL PADA PERAWAT PADA KLIEN
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Kesan Perawat :
RENCANA KEPERAWATAN

DIAGNOSA TUJUAN DAN KRITERIA


TGL INTERVENSI RASIONAL TTD
KEPERAWATAN STANDART
RENCANA KEPERAWATAN

NO. DIAGNOSA TUJUAN DAN KRITERIA


TGL INTERVENSI RASIONAL TTD
DX KEPERAWATAN STANDART
CATATAN TINDAKAN ( IMPLEMENTASI)

DIAGNOSA
TGL TINDAKAN KEPERAWATAN DAN HASIL PARAF
KEPERAWATAN
CATATAN TINDAKAN ( IMPLEMENTASI)

DIAGNOSA TINDAKAN KEPERAWATAN


PARAF
TGL KEPERAWATAN DAN HASIL
FORMAT RESUME KESEHATAN JIWA

IMPLEMENTASI
INTERVENSI
DX KEPERAWATAN EVALUASI
KEPERAWATAN
CATATAN PERKEMBANGAN

DIAGNOSA EVALUASI / SOAP


TGL PARAF
KEP.