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Makanan Pantangan
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I. Nasehat Pulang
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J. Pendidikan Kesehatan
□ Perawatan perineum
□ Perawatan tali pusat
□ Pijat bayi
□ Perawatan payudara
□ Perawatan luka
□ KB

□ Nutrisi dan Aktivitas Ibu
□ Senam nifas
□ Lainnya
Program Profesi Ners PSIK UNDIP Angkatan XVIII -4-

.............................................................. ....................... Alamat : .................................. Tanggal keluar : .. Tanggal masuk : ....... No register : .. ........................................... : ..... RSUD KRT SETJONEGORO WONOSOBO Program Profesi Ners PSIK UNDIP Angkatan XVIII -1- Nama Pasien : ....... ........................................... .................. .............................DISCHARGE PLANNING Ruang : ....................................................................................................................... ...... Umur ................................................................... ........................

............................................. ............... ........... ........................................... Obat yang perlu diminum dirumah No Nama Obat Aturan minum 1 sblm/stlh makan 3 4 5 Program Profesi Ners PSIK UNDIP Angkatan XVIII -2D........................................................................ ................................... ........... ................................................................................. ......................... Aktivitas yang Harus Dilakukan ..... Masalah Keperawatan yang Masih Ada .. ..................................................................... ......................... .....................................2 A.................................................................... Waktu Kontrol Hari/tanggal ......................................... F......... Dosis sblm/stlh makan sblm/stlh makan sblm/stlh makan sblm/stlh makan .................................................. B................ Tempat Kontrol □ Dokter praktek □ Rumah sakit □ Puskesmas □ Bidan □ Lain-lain . ...................................... .................................................................................... ........ E................ ........ Alasan Pulang □ Sembuh □ Membaik/diijinkan □ Permintaan sendiri □ Dirujuk C....

..................... ........... ................................................... ...... ................................................... ............... ................................................. ......... ........ ....................................................................... Aktivitas yang Perlu Dibatasi .............................................................................................................................................................................. .............................. ..................................... ........................................................................................ Program Profesi Ners PSIK UNDIP Angkatan XVIII -3- ............................ G.........................