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ANALISA DATA

Nama Pasien : ........................................................


Diagnosa : ........................................................

MASALAH
NO DATA ETIOLOGI
KEPERAWATAN

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DAFTAR DIAGNOSA KEPERAWATAN

Nama Pasien : ........................................................


Diagnosa : ........................................................

No. Dx TANGGAL DIAGNOSA KEPERAWATAN TANGGAL TANDA


MUNCUL TERATASI TANGAN

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RENCANA ASUHAN KEPERAWATAN

Diagnosa Keperawatan: …………………………………………………………………………….............


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Tujuan: …………………..…………………………………………………………………………….............
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Kriteria Hasil :
NOC
No. Indikator 1 2 3 4 5

Keterangan Penilaian :
1 :
1 :
2 :
3 :
4 :

NIC :
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IMPLEMENTASI

Nama Pasien : ........................................................


Diagnosa : ........................................................

TTD &
No. Dx.
Tgl Jam Tindakan Keperawatan Respon Klien Nama
Kep
Terang

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CATATAN PERKEMBANGAN (PROGRESS NOTE)

Diagnosa Keperawatan:
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…………NOC :
Tanggal Observasi dan Hasil
No Indikator
1 2 3 4 S 1 2 3 4 S 1 2 3 4 S

Keterangan Penilaian :
- : tidak sesuai
+ : sesuai yang diharapkan
S : scoring

Keterangan Skoring :
1 :-
2 : 1+
3 : 2+
4 : 3+
5 : 4+
EVALUASI
Hari/
No Dx Tanda
Tanggal/ Evaluasi
tangan
Jam

S: ...........................................................................................
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O:
NOC:
Score
Indikator
Awl Tgt Akr

A: Masalah sesuai dengan NOC sudah / belum teratasi


P: Intervensi dihentikan / dilanjutkan dan didelegasikan
kepada perawat dinas ……… :
1. NIC : ……………………………………………………….
2. NIC : ……………………………………………………….
*Coret yang tidak perlu
RESUME KEPERAWATAN
NAMA KLIEN : ......................................... TANGGAL : .........................................
DX. MEDIS : ......................................... RUANG : .........................................

S O A P I E

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