1. Identitas Klien:
Nama/inisial :
Umur :
L/P :
Alamat :
Tempat Perawatan :
Tanggal dirawat :
Tanggal Pengkajian :
Data subyektif:
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Data obyektif:
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3. Masalah keperawatan
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5. Implementasi dan evaluasi
Tanggal/ Masalah kep. Implementasi Evaluasi
pukul