S

DS
ITUATION
: ..................................................................................................................................
................................................................................................................................
DO : ..................................................................................................................................
................................................................................................................................

B ACKGROUND
Riwayat sebelumnya: ................................................................................................
Riwayat Medis : ..............................................................................................
Terapi yang sudah diberikan : .................................................................
Hasil Pemerisaan Diagnostik yang sudah dilakukan : ...................
................................................................

A SSESMENT
Implementasi : ...........................................................................................................
............................................................................................................
Analisa dan Pertimbangan Perawat : ...............................................................
............................................................................................................
Kesimpulan masalah keperawatan : ...................................................................

R EKOMENDASI
Saran : ...................................................................................................................................
....................................................................................................................................

Pemeriksaan yang diperlukan : .................................................................................

Perubahan Terapi : Ada / Tidak Ada*

Yaitu .............................
Pendapat perawat untuk mengatasi masalah : ..................................................
...................................................................................................................................
Waktu yang diharapkan perawat untuk menangani masalah :
...................................................................................................................................
Perlu konsultasi ke dokter : perlu / tidak perlu*
Yaitu...................
Perlu pindah ruangan : perlu / tidak perlu*
Ke unit ......................

Tanda (*) : coret yang tidak perlu