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Nama : …………………………………………… Umur : …………………………………………… Diagnosa : …………………………………………… Ruangan : …………………………………………… Hari, tanggal, jam KU N (x/meni t) RR (x/menit) T ( o C) Keteranga n ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ………………………. ............ ............ ..... ............ ............ ..... ............ ............ ..... ............ ............ ..... ............ ............ ..... ............ ............ ..... ............ ............ ..... ............ …………... …………... …………... …………... …………... …………... …………... …………... …………... …………... …………... …………... …………... …………... …………... …………... …………... …………... …………... …………... …………... …………... …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. ……………. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. …………….. ……………..

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Nama : Umur: Diagnosa : Ruangan: Hari, tanggal, jam KUN(x/menit)RR(x/menit)T (oC) Keterangan ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Nama : Umur: Diagnosa : Ruangan: Hari, tanggal, jam KUN(x/menit)RR(x/menit)T (oC) Keterangan ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Nama : Umur: Diagnosa : Ruangan: Hari, tanggal, jam KUN(x/menit)RR(x/menit)T (oC) Keterangan ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Nama : Umur: Diagnosa : Ruangan: Hari, tanggal, jam KUN(x/menit)RR(x/menit)T (oC) Keterangan ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Nama : Umur: Diagnosa : Ruangan: Hari, tanggal, jam KUN(x/menit)RR(x/menit)T (oC) Keterangan ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................


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