NAMA : …………………………………………………………………….
UMUR : …………………………………………………………………….
NAMA KK : …………………………………………………………………….
ALAMAT : …………………………………………………………………….
DIAGNOSA : …………………………………………………………………….
NO. RM : …………………………………………………………………….
HASIL
NO MONITORING 15 MENIT 15 MENIT 15 MENIT 15 MENIT
I II III IV
1. Kesadaran/GCS
Eye
Verbal
Movement
2. Vital Sign
Tekanan Darah
Nadi
Respirasi
. Suhu
Warna kulit
Dawan, .......................20...
Petugas
(.....................................)