SZFKA YKL@T ZFZF B@SNKZY

Gd. Y`kl G5/;> Lofp.Cjk Iulk` Gklkrtk Tjdp.(=3;) >>=8333, >>===88, Bkx. (=3;) >>===23

S@EI@KE LJXJEKEHKE LD@E@Y (ID@E@IKD ]S@R@DJHJ)

]JSKXKT LD@E@L @@@ KEKL NKE CKP@

@njet`tks 7

Ekfk ]jrkwkt/C`nke 7

Ze`t Ljrjk 7

]jen`n`lke Borfkd 7

YTS Tkehhkd Tjrc`t 7

Tkehhkd Cjrkla`r 7

Y@] Tkehhkd Tjrc`t 7

Tkehhkd Cjrkla`r 7
]jdkt`ake ykeh n``lut` 7

EO Thd Gje`s ]jdkt`ake @est`tus` ]jeyjdjehhkrk

]jdkt`ake ]jdkt`ake

]jreyktkke 7

Ykyk fjeyktklke ckawk skyk lofpjtje uetul fjfcjr`lke ksuake

ljpjrkwktke/ljc`nkeke 7 njehke prosjnur tjle`s sjpjrt` tjriketuf n`ckwka `e`
sjckhk` ckh`ke nkr` ljwjekehke ld`e`s (id`e`ikd ]r`v`djhj) cjrnkskrlke
stktus ljsjaktke skkt `e`, pjen`n`lke, nke ktku pjdkt`ake ykeh tjdka skyk
jkdke` sjrtk pjehkdkfke ykeh skyk f`d`l`.

]JSKXKT LD@E@L @ KEKL NKE CKP@

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF ;
B@SNKZY
• ]jrkwkt ld`e`s @@ (Knvkeij Cjh`eejr) fjf`d`l` dktkr cjdklkeh pjen`n`lke N-
@@@ Ljpjrkwktke njehke pjehkdkfke ljrjk ≪ > tkaue nke fjejkdke` fksk
ld`e`s djvjd @@ sjdkfk 2 - 9 tkaue.

• Yjnkehlke Ejrs njehke pjehkdkfke ljrjk ≪ 3 tkaue nke nke fjejkdke`

fksk ld`e`s djvjd @@ sjdkfk > - 8 tkaue.

Melaksanakan lntervensi Spesifik Keperawatan Secara Mandiri

]je`dk`k Sjlofjenks`
Eo e Ksjsor/]jjr
. Ksuake Ljpjrkwktke Fken`r` Hroup
F NY L NY
; Fjejr`fk ]ks`je Ckru
3 Fjejjdkslke Bks`d`tks ykeh knk
3 Fjenjehkrlke Ljduake ]ks`je
> Fjdklulke @njet`filks` rjs`lo pks`je jktua
5 Fjdklulke `etjrvjes` pjeijhkake pks`je jktua
2 Fjffks`d`tks` pks`je uetul cjr`cknka
8 Fjdklulke lofue`lks` tajrkpjut`l pknk kekl nke
cky`
9 Fjdklulke fksskhj pknk krjk tucua ykeh tjrtjlke
1 Fjdklulke Idkpp`eh R`crks`
Fjffks`d`tks` fklke pknk pks`je ykeh t`nkl
;= fkfpu fklke sjen`r`
;; Fjffks`d`tks` pks`je ykeh nkpkt fklke sjen`r`
;3 Fjfcjr`lke eutr`s` v`k EHT
Fjenolufjetks`lke jufdka fklkeke ykeh
;3 n`akc`slke pks`je
;> Fjdklulke pjenolufjetks`ke @etklj Output
;5 Fje`fckeh Cjrkt Cknke
;2 Fjehulur D`ehlkr Djehke
;8 Fjehulur T`ehh` Cknke
;1 Fjeodoeh pks`je C.K.L n` tjfpkt t`nur

;9
t`nurFjeodoeh
3= pks`je
Fjfcjr` C.K.C n`
Auleka tjfpkt
Sjenka
3; Fjfcjr` Auleka T`ehh`
33 Fjfcjr` Hdyijr`e Ypu`t
33 Fjdklulke vudvk
ayh`ej 3> Fjeiui` Tkehke
35 Fjfkskeh nke fjdjpks Fksljr
32 Fjfkskeh nke fjdjpks skrueh tkehke Ytjr`d
38 Fjffks`d`tks` pks`je fken` n` tjfpkt t`nur
31 Fjey`lkt h`h` pks`je
39 Fjrkwkt h`h` pkdsu
3= Fjfcjrs`alke fudut pks`je t`nkl
sknkr 3; Fjey`s`r rkfcut pks`je
33 Fjehhket` ]klk`ke pks`je

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF 3

33 Fjehhket` kdkt tjeue
3> Fjehhket` kdkt tjeue njehke pks`je n` ktkseyk
35 Fjeiui` rkfcut pks`je n` tjfpkt t`nur
32 Fjfotoeh Lulu ]ks`je
38 Fjejkhk ljcjrs`ake d`ehluehke pks`je
31 Fjehktur ]os`s` Bowdjr (;/3 nunul)
39 Fjehktur ]os`s` Yyf
>= Fjehktur ]os`s` Trjenjdjecurh
>; Fjehktur ]os`s` Norskd Sjiufcjet
>3 Fjehktur ]os`s` D`totof`j
>3 Fjf`r`ehlke ]ks`je
Fjffks`d`tks` pks`je p`enka nkr` tjfpkt t`nur lj
>> ljrjtk noroeh nke sjckd`leyk
Fjffks`d`tks` pks`je ykeh p`enka sjen`r` lj
>5 ljrjtk noroeh nke sjckd`leyk
Fjffks`d`tks` pks`je p`enka nkr` tjfpkt t`nur lj
>2 lurs` ronk
Fjffks`d`tks` pks`je p`enka nkr` foc`d lj ljrjtk
>8 noroeh nke sjckd`leyk
>1 Fjehulur suau cknke fjdkdu` kx`kd
>9 Fjehulur suau cknke fjdkdu` keus
5= Fjehulur suau cknke fjdkdu`
tjd`ehk
5; Fjehulur suau cknke fjfklk` @efrk Sjn/Nka`
53 Fjehulur tjlkeke nkrka
53 Fjeha`tueh njeyut ekn` / njeyut jketueh
5> Fjeha`tueh pjrekpkske
Fjenolufjetks`lke Tkenk-tkenk R`tkd pknk Borf
55 Lurvj Akr`ke
52 Fjfcjr` lofprjs akehkt
58 Fjfcjr` cud` cud` pkeks
51 Fjfcjr`lke lofprjs n`eh`e
59 Fjfkskeh ioenof iktajtjr
2= Fjrkwkt ]ks`je ykeh klke fje`ehhkd
2; Fjrkwkt pks`je ykeh sunka
fje`ehhkd
23 Fjdklulke pjenolufjetks`ke njehke ck`l nke cjekr
23 Fjey`kplke pks`je pudkeh

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF 3

]JSKXKT LD@E@L @ KEKL NKE CKP@

Fjdklskeklke @etjrvjes` Ypjs`fil Ljpjrkwktke Yjikrk Lodkcorks`

]kje`dk`
ke Sjlofjenks`
Fken`r` Ksjsor
Eo
. Ksuake Ljpjrkwktke F NY L NY

; Fjdklulke Sjsus`tks` Gketueh ]kru

3 Fjdklulke Sjsus`tks` Gketueh ]kru pknk kekl

3 ]jfcjr`ke Ols`hje njehke ekskd ikeudj

> ]jfcjr`ke Ols`hje njehke s`fpdj fksl

5 Fjdklulke Kf @efus

2 Fjeha`tueh tjtjske `efus

8 Fjehhket` ik`rke `efus

1 Fjdklulke Kf Iktajtjr

9 Fjdklulke Kf EHT

;= Fjfkskeh @efus ]ufp

;; Fjehkfc`d skfpdj nkrka vjek

;3 Fjffks`d`tks` pks`je uetul pjfjr`lskke Zr`ej

;3 Fjffks`d`tks` pks`je uetul pjfjr`lskke Bkjijs

;> Fjfcjr` tajrkp` ockt pjr orkd

;5 Fjfcjr` tajrkp` ockt pjr @R dkehsueh

;2 Fjfcjr` tajrkp` ockt pjr @R t`nkl dkehsueh

;8 Fjfcjr`lke eutr`s` pkrjetjrkd

;1 Fjfcjr` tajrkp` ockt pjr @F

;9 Fjfcjr` tajrkp` ockt pjr YI

3= Fjfcjr` tajrkp` ockt pjr @I

3; Fjfcjr` tajrkp` ockt sucd`ehukd

33 Fjfcjr`lke tajrkp` ockt tjtjs

33 Fjfcjr`lke tajrkp` ockt suppos`tor`k

3> Fjfcjr`lke tajrkp` ockt fjdkdu` lud`t/ top`ikd

35 Fjehkfc`d Ykfpdj Nkrka ]jr`fjr

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF >
 32 Fjdklulke pjrkwktke dulk lji`d

38 Fjfcjr`lke `eakdks`

31 Fjdklulke pjrs`kpke opjrks` lji`d

39 Fjdklulke pjrs`kpke opjrks` sjnkeh

3= Fjfkskeh O]K
3; Fjdjpkslke O]K

33 Fjffks`d`tks` pks`je uetul B`s`otajrkp`

33 Fjffks`d`tks` pks`je uetul t`enklke Skn`odoh`

3> Fjffks`d`tks` pks`je uetul loesud lj

]od`ld`e`l

35 Fjey`kplke pks`je uetul t`enklke

n`kheost`l
Gklkrtk, ......................................
Iktktke 7
]JSKXKT LD@E@L @@ KEKL NKE CKP@
• Cjr`lke Ijl D`st Odja Ksjs` pknk lodof F
( Fken`r` ) nke NY (N`supjrv`s`)
Melaksanakan lntervensi Spesifik Keperawatan Secara Mandiri
]je`dk` Sjlofjenk
• Cjr`lke Ijl D`st odja Ksjsor ]knk lodof
L (Lofpjtjes`) nke NY (N`supjrv`s`)
( ................................k...e....................) s`
Fken`r` Ksjsor
Ksuake Ljpjrkwktke F NY L NY
Eo
Fjdklulke @etjrvjes` spjs`fil Ljpjrkwktke
; sjikrk Fken`r` ]L @
3 Yjrka tjr`fk pks`je nkr` ]od`ld`e`l nke ZHN lj rkwkt `ekp
3 Fjejjfput ]ks`je Lj Lkfkr opjrks`
>
Fjdklulke ]jrkwktke pks`je sjsunka opjrks`
5 Fjehketkr pks`je p`enka lj Sukehke dk`e
2 Fjehketkr pks`je p`enka/Sujul lj Sufka Ykl`t dk`e
8 Fjehketkr pks`je lj Lkfkr Opjrks`
1 Fjejjfput pks`je nkr` @IZ/E@IZ/]@IZ
9 Fjdklulke Jvkduks` t`enklke ljpjrkwktke
;= Fjfcukt Sjsufj Ljpjrkwktke
;; Fjdklulke Jnulks` pks`je
;3 Fjeha`tueh Ckdkeij Ik`rke
;3 Fjdklulke ]jfketkuke Ajfon`ekf`l
;> Fje`dk` tkenk ’ tkenk Nja`nrks`
;5 Fjdklulke Tjae`l ]jeyjtjr`dke Kdkt
;2 Fjehopjrks`lke trkesfus` pufp
;8 Fjey`kplke kdkt - kdkt uetul vjek sjit`j

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF 5

;1 Fjdklulke pjehlkj`ke tufcua ljfckeh
;9 Fjdklulke pjehlkj`ke `ffue`sks`
3= Fjeha`tueh ljcutuake ik`rke pknk kekl nke cky`

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF 5

3;Fjfken`lke cky` ( Sukeh Ejoektus )
33Fjehopjrks`oekdlke kdkt fototjrkp`
33Fjehopjrks`oekdlke kdkt `elucktor 3>Fjeha`tueh nowe siorj pknk cky`
35Fjehopjrks`oekdlke `efket wkrfjr

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF 2

Melaksanakan lntervensi Spesifik Keperawatan Secara Kolaborasi

]je`dk` Sjlofjenk
ke s`
Eo Ksjsor

Fken`r`
. Ksuake Ljpjrkwktke Fjfckik nke
; Fjdklulke SG] pknk cky` ( Sukeh Ejoektus ) 32 fjdkporlke
aks`d
3 Fjfkskeh @R d`ej kekl nke cky` Dkcorktor`u
f pknk
3 Fjfcjr`lke ols`hje njehke ajkn cox noltjr
>
Fjeha`tueh lorjls` ockt nke ik`rke kekl nke cky@ Fjehketkr pks`je
5 Fjfkskeh OHT / EHT uetul ]jfjr`lskke/
Fjdklulke @etjrvjes` spjs`fil Ljpjrkwktke T`enklke n` dukr
2 sjikrk Lodkcorks` ]L @
8 Fjfcjr`lke Ols`hje njehke suehlup Sjcrjkta`eh
1 Fjfcjr`lke Ols`hje njehke suehlup Eoe Sjcrjkta`eh
9 Fjfcjr`lke Ols`hje njehke fksljr vjetur`
;= Fjdklulke suit`oe djwkt fudut/a`nueh/trkiajostof`j
;; Fjey`kplke pks`je opjrks` cjskr
;3 Fjey`kplke pks`je Opjrks` Lausus
;3 Fjey`kplke pks`je uetul ]ueit`j ]djurk
;> Fjey`kplke pks`je uetul Dufckd ]ueit`j
;5 Fjey`kplke ]ks`je nke kdkt uetul pjfkskehke JTT
;2 Fjehopjrks`lke pjrjlkfke JLH
;8 Fjfkskeh Nowjr Iktajtjr
;1 Fjfkskeh sdkeh dkfcueh/EHT
;9 Fjfkskeh @efus
3= Fjfkskeh Yyr`ehj ]ufp
3; Fjffks`d`tks` pks`je uetul ]jrf`etkke Nkrka
33 Fjfcjr` Trkesfus` Nkrka
33 Fjfcjr`lke tajrkp` T`trks` C`iekt, LID
3> Fjrkwkt ]ks`je njehke Iodostof`j ( Ytofk )
35 Fjehkfc`d Nkrka Krtjr`
32 Fjdkt`a SOF
38 Fjehopjrks`lke kdkt oxyfjtr`
31 Fjehopjrks`lke C]F
39 Fjdklulke pjrkwktke Dulk
Yjnkeh 3= Fjdklulke ]jrkwktke Dulk
Cjskr
Fjdklulke ]jrkwktke ]knk ]ks`je Pkeh
3; Tjrpkskeh Nrk`eksj
33 Fjdklulke ]jrkwktke Dulk Cklkr Hrknj @ ( 4 3= % )
33 Fjdklulke ]jrkwktke Dulk Cklkr Hrknj @@ ( 3= % ’ >=
% ) 3> Fjdklulke ]jrkwktke Dulk Cklkr Hrknj @@@ ( 5 >= %
)
35 Fjdklulke kehlkt Gka`tke

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF 8

F NY L NY
38 SYAG

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF 8

 Fjehaucueh` Sufka Ykl`t dk`e uetul T`enklke,
31
]jfjr`lskke, Sujul pks`je
39 Fjrjlkf Yp`rofjtr`
>= Fjrjlkf Kun`ofjtr`
>; Fjdklulke Ijl Hudk Nkrka (Hdulotjst)
>3 Fjey`kplke Kdkt uetul T`enklke Klupuetur
>3 Fjey`kplke kdkt uetul t`enklke @ei`s`
>> Fjey`kplke kdkt uetul t`enklke Jxtjrpkt`j
>5 Fjenkfp`eh` noltjr R`s`tj
>2 Fjrjlkf JJH
Fjdklulke ]jeijhkake Nke ]jekehhudkehke
>8 @efjls` Eksolof`kd
>1 ]jehjdodkke ]ks`je Njehke ]jeykl`t Fjeudkr
>9 Fjdklulke ]jehhket`ke prosjnur `evks`f
5= Fjfkskeh C`nk`
5; Fjfkskeh Ejil Iodjr
53 Fjdklulke Lufcka Dkfcueh
53 Fjfcjr`lke Tajrkp` Ockt
Yjnkt`f 5> Fjey`kplke Kdkt Zetul
@etucks`
55 Fjfcjr`lke Ockt ’ ockt Jfjrhjeiy nke D`fj Ykv`eh
52 Fjdklulke `etjrprjtks` aks`d Yl`e tjst nke Fketoux tjst
58 Fjey`kplke Kdkt Rjek Yjit`j

Iktktke 7 Gklkrtk, ......................................

• Cjr`lke Ijl D`st Odja Ksjs` pknk lodof F Pemohon

( Fken`r` ) nke NY (N`supjrv`s`)

• Cjr`lke Ijl D`st odja Ksjsor ]knk lodof

L (Lofpjtjes`) nke NY (N`supjrv`s`) ( .......................................................)

]JSKXKT LD@E@L @@@ KEKL NKE CKP@

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF 1

Melaksanakan lntervensi Spesifik Keperawatan Secara Mandiri

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF 1

 ]je`dk` Sjlofjenk
ke s`
Eo Ksjsor

Fken`r`
. Ksuake Ljpjrkwktke F NY F NY
Fjdklulke @etjrvjes` spjs`fil Ljpjrkwktke
; sjikrk Fken`r` ]L @ nke ]L @@
Fjdklulke Tr`pdj Fkeuvjr ( Ajkn D`ft, Ia`e D`ft,
3 Gkw Trust )
3 Fjdklulke ]je`dk`ke Ytktus Ejurodoh`s
>
Fjey`kplke Kdkt Rjek Yjit`j
5 Fjdklulke Loesjd`eh pknk ]ks`je
2 Fjfcjr`lke Fot`vks` Yp`r`tukd
8 ]jrkwktke lkehkroo fotajr ikrj
1 Opjrks`oekd Cucdj I]K]
9 Fjdklulke pjrs`kpke t`enklke trkesfusj tulkr

Melaksanakan lntervensi Spesifik Keperawatan Secara Kolaborasi

]je`dk`Sjlofjenk
kes`
Eo Fken`r`Ksjsor
. Ksuake Ljpjrkwktke
fil Ljpjrkwktke sjikrk Lodkcorks` ]L @ nke ]L @@
;
cjr`lke Tajrkp` Ockt Ekrlot`lk
3
ke pjeuejkeh fjn`i Fjdklulke loorn`eks` njehke pjeuejkeh eoe n`kheost`i Fjfcjr`lke Trk`e`eh cjljrjkskfk njehke N`
3
fk njehke N`ldkt Sufka
>5
2

Iktktke 7
Gklkrtk, ......................................

Cjr`lke Ijl D`st Odja Ksjs` pknk lodof F

Pemohon
•

( Fken`r` ) nke NY (N`supjrv`s`)

• Cjr`lke Ijl D`st odja Ksjsor ]knk lodof

L (Lofpjtjes`) nke NY (N`supjrv`s`)
( .......................................................)

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF 9

 SJLOFJENKY@ KYJYOS / F@TSK CJYTKS@

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF 9

 DiSetujui DiSetujui Dengan Tidak DiSetujui
Catatan

Tanggal :

Catatan :

ASeSor / Mitra BeStari :

No Nana SpeSialiSaSi Tanda Tangan

KOMITE KEPERAWATAN/SUB KOMITE KREDENSIAL

DiSetujui DiSetujui Dengan Tidak DiSetujui

Catatan

Tanggal :

Catatan :

Ketua Konite Keperawatan Ketua Sub Konite KredenSial

( (
) )

ID@E@IKD ]S@R@DJHJ LJ]JSKXK^KE SY ZFZF ;