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ANALISA DATA

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


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

NO DATA (DS/DO) PROBLEM ETIOLOGI


DIAGNOSA KEPERAWATAN

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


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

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

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

No. Tanggal SLKI SIKI


IMPLEMENTASI KEPERAWATAN

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


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

Tanggal/Jam No. Dx. Tindakan Keperawatan Paraf


EVALUASI

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


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

Tanggal/Jam No. Dx. Evaluasi (SOAP) Paraf

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