ANALISA DATA

Nama :.................................. No. RM :..................................................

Umur :.................................. Dx Medis :...................................................
Ruang rawat :.................................. Alamat :...................................................

NO DATA FOKUS ETIOLOGI PROBLEM

S: ……………………
………………………
……………………….
………………………
………………………
………………………
………………………

O: ……………………
………………………
……………………….
………………………
………………………
………………………
……………………….

DIAGNOSA KEPERAWATAN
 1. ................................................................................................................................................
.................................................................................................................................
2. ................................................................................................................................................
.................................................................................................................................
3. ................................................................................................................................................
.................................................................................................................................
4. ................................................................................................................................................
..................................................................................................................................
5. ...........................................................................................................................
……………........................................................................................................................

RENCANA TINDAKAN KEPERAWATAN

Inisial Klien :........................................

Ruangan :........................................
No.RM :........................................

Hari, Rencana Tindakan Keperawatan Paraf

Diagnosa
tgl,
Keperawatan NOC NIC Rasional
jam

IMPLEMENTASI ASUHAN KEPERAWATAN

Inisial Klien :................................................

Ruangan : ...............................................
No. R.M :................................................

Hari,
Diagnosa Implementasi Respon
tgl, Paraf
Keperawatan Keperawatan (EvaluasiFormatif)
jam

EVALUASI SUMATIF/
CATATAN PERKEMBANGAN
Inisial Klien : ............................................
Ruangan :.............................................
No. R.M :.............................................
Hari, tgl, Diagnosa Evaluasi Sumatif
Paraf
jam keperawatan (SOAP)