ANALISA DATA

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

Umur : ......................... Th/Bln Ruang : ................................

NO DATA (DS/DO) ETIOLOGI MASALAH

 DAFTAR DIAGNOSA KEPERAWATAN

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

Umur : ......................... Th/Bln Ruang : ................................

NO DIAGNOSA KEPERAWATAN
 RENCANA TINDAKAN KEPERAWATAN
Nama Pasien : ................................................. No. RM : ...............................
Umur : ......................... Th/Bln Ruang : ................................

DIAGNOSA
KEPERAWATAN : ....................................................................................................................................................................................................
........
.
No. Tujuan dan Kriteria Hasil Rencana Tindakan Rasional Paraf
DIAGNOSA
KEPERAWATAN : ....................................................................................................................................................................................................
........

No. Tujuan dan Kriteria Hasil Rencana Tindakan Rasional Paraf

 TINDAKAN KEPERAWATAN

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

Umur : ......................... Th/Bln Ruang : ................................

Tanggal/ No.
Tindakan Keperawatan Paraf
Jam Dx.
 CATATAN PERKEMBANGAN

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

Umur : ......................... Th/Bln Ruang : ................................

Tanggal/ No. Catatan Perkembangan Paraf

Jam Dx.
 E VALUAS I
Nama Pasien : ................................................. No. RM : ...............................
Umur : ......................... Th/Bln Ruang : ................................

Tanggal/ No. Evaluasi Paraf

Jam Dx.