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PENILAIAN RISIKO JATUH PASIEN DEWASA SKALA JATUH MORSE

PENILAIAN RISIKO JATUH PASIEN DEWASA SKALA JATUH MORSE (≥ 18 TAHUN – USIA < 65 TAHUN)

<table class="MsoTableGrid" border="1" cellspacing="0" cellpadding="0" style="border: none;"><tbody><tr>
 <td width="43" style="width:.45in;border:solid black 1.0pt;mso-border-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 No.<o:p></o:p>
 </td>
 <td width="176" style="width:132.3pt;border:solid black 1.0pt;mso-border-themecolor:
 text1;border-left:none;mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 Risiko<o:p></o:p>
 </td>
 <td width="58" style="width:.6in;border:solid black 1.0pt;mso-border-themecolor:
 text1;border-left:none;mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 Skala<o:p></o:p>
 </td>
 <td width="60" style="width:45.0pt;border:solid black 1.0pt;mso-border-themecolor:
 text1;border-left:none;mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 Skor<o:p></o:p>
 </td>
 <td width="114" style="width:85.5pt;border:solid black 1.0pt;mso-border-themecolor:
 text1;border-left:none;mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 Skoring 1<o:p></o:p>
 Tgl : 02/05/24<o:p></o:p>
 Jam :<o:p></o:p>
 </td>
 <td width="114" style="width:85.5pt;border:solid black 1.0pt;mso-border-themecolor:
 text1;border-left:none;mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 Skoring 2<o:p></o:p>
 Tgl :<o:p></o:p>
 Jam :<o:p></o:p>
 </td>
 <td width="114" style="width:85.5pt;border:solid black 1.0pt;mso-border-themecolor:
 text1;border-left:none;mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 Skoring 3<o:p></o:p>
 Tgl :<o:p></o:p>
 Jam :<o:p></o:p>
 </td>
 <td width="108" style="width:81.0pt;border:solid black 1.0pt;mso-border-themecolor:
 text1;border-left:none;mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 Skoring 4<o:p></o:p>
 Tgl :<o:p></o:p>
 Jam :<o:p></o:p>
 </td>
 </tr>
 <tr>
 <td width="43" style="width:.45in;border:solid black 1.0pt;mso-border-themecolor:
 text1;border-top:none;mso-border-top-alt:solid black .5pt;mso-border-top-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 1<o:p></o:p>
 </td>
 <td width="176" valign="top" style="width:132.3pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Riwayat jatuh, yang baru atau 3 bulan terakhir<o:p></o:p>
 </td>
 <td width="58" style="width:.6in;border-top:none;border-left:none;border-bottom:
 solid black 1.0pt;mso-border-bottom-themecolor:text1;border-right:solid black 1.0pt;
 mso-border-right-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <strike>Tidak</strike><o:p></o:p>
 Ya<o:p></o:p>
 </td>
 <td width="60" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid black 1.0pt;mso-border-bottom-themecolor:text1;border-right:solid black 1.0pt;
 mso-border-right-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 0<o:p></o:p>
 25<o:p></o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> 3</o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="108" valign="top" style="width:81.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 </tr>
 <tr>
 <td width="43" style="width:.45in;border:solid black 1.0pt;mso-border-themecolor:
 text1;border-top:none;mso-border-top-alt:solid black .5pt;mso-border-top-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 2<o:p></o:p>
 </td>
 <td width="176" valign="top" style="width:132.3pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Diagnosis medis sekunder ( > 2 diagnosis medis)<o:p></o:p>
 </td>
 <td width="58" style="width:.6in;border-top:none;border-left:none;border-bottom:
 solid black 1.0pt;mso-border-bottom-themecolor:text1;border-right:solid black 1.0pt;
 mso-border-right-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Tidak<o:p></o:p>
 Ya<o:p></o:p>
 </td>
 <td width="60" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid black 1.0pt;mso-border-bottom-themecolor:text1;border-right:solid black 1.0pt;
 mso-border-right-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 0<o:p></o:p>
 25<o:p></o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> 5</o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="108" valign="top" style="width:81.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 </tr>
 <tr>
 <td width="43" style="width:.45in;border:solid black 1.0pt;mso-border-themecolor:
 text1;border-top:none;mso-border-top-alt:solid black .5pt;mso-border-top-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 3<o:p></o:p>
 </td>
 <td width="176" valign="top" style="width:132.3pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Alat bantu jalan:<o:p></o:p>
 <p class="MsoListParagraphCxSpFirst" style="margin-top:0in;margin-right:0in;
 margin-bottom:0in;margin-left:.3in;margin-bottom:.0001pt;mso-add-space:auto;
 text-indent:-.25in;line-height:normal;mso-list:l0 level1 lfo1">-         
 Bed rest dibantu perawat<o:p></o:p>
 <p class="MsoListParagraphCxSpMiddle" style="margin-top:0in;margin-right:0in;
 margin-bottom:0in;margin-left:.3in;margin-bottom:.0001pt;mso-add-space:auto;
 text-indent:-.25in;line-height:normal;mso-list:l0 level1 lfo1">-         Penopang/tongkat/ walker<o:p></o:p>
 <p class="MsoListParagraphCxSpLast" style="margin-top:0in;margin-right:0in;
 margin-bottom:0in;margin-left:.3in;margin-bottom:.0001pt;mso-add-space:auto;
 text-indent:-.25in;line-height:normal;mso-list:l0 level1 lfo1">-         
 Berpegang pada perabot/furniture<o:p></o:p>
 </td>
 <td width="58" style="width:.6in;border-top:none;border-left:none;border-bottom:
 solid black 1.0pt;mso-border-bottom-themecolor:text1;border-right:solid black 1.0pt;
 mso-border-right-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="60" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid black 1.0pt;mso-border-bottom-themecolor:text1;border-right:solid black 1.0pt;
 mso-border-right-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 0<o:p></o:p>
 15<o:p></o:p>
 30<o:p></o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> 5</o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="108" valign="top" style="width:81.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 </tr>
 <tr>
 <td width="43" style="width:.45in;border:solid black 1.0pt;mso-border-themecolor:
 text1;border-top:none;mso-border-top-alt:solid black .5pt;mso-border-top-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 4<o:p></o:p>
 </td>
 <td width="176" valign="top" style="width:132.3pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Terpasang infuse/ terapi heparin lock/ iv<o:p></o:p>
 </td>
 <td width="58" style="width:.6in;border-top:none;border-left:none;border-bottom:
 solid black 1.0pt;mso-border-bottom-themecolor:text1;border-right:solid black 1.0pt;
 mso-border-right-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Tidak<o:p></o:p>
 Ya<o:p></o:p>
 </td>
 <td width="60" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid black 1.0pt;mso-border-bottom-themecolor:text1;border-right:solid black 1.0pt;
 mso-border-right-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 0<o:p></o:p>
 25<o:p></o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> 5</o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="108" valign="top" style="width:81.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 </tr>
 <tr>
 <td width="43" style="width:.45in;border:solid black 1.0pt;mso-border-themecolor:
 text1;border-top:none;mso-border-top-alt:solid black .5pt;mso-border-top-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 5<o:p></o:p>
 </td>
 <td width="176" valign="top" style="width:132.3pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Cara berjalan/ berpindah :<o:p></o:p>
 <p class="MsoListParagraphCxSpFirst" style="margin-top:0in;margin-right:0in;
 margin-bottom:0in;margin-left:.3in;margin-bottom:.0001pt;mso-add-space:auto;
 text-indent:-.25in;line-height:normal;mso-list:l0 level1 lfo1">-         
 Normal/ bed rest/ imobilisasi<o:p></o:p>
 <p class="MsoListParagraphCxSpMiddle" style="margin-top:0in;margin-right:0in;
 margin-bottom:0in;margin-left:.3in;margin-bottom:.0001pt;mso-add-space:auto;
 text-indent:-.25in;line-height:normal;mso-list:l0 level1 lfo1">-         
 Lemah<o:p></o:p>
 <p class="MsoListParagraphCxSpLast" style="margin-top:0in;margin-right:0in;
 margin-bottom:0in;margin-left:.3in;margin-bottom:.0001pt;mso-add-space:auto;
 text-indent:-.25in;line-height:normal;mso-list:l0 level1 lfo1">-         
 Terganggu<o:p></o:p>
 </td>
 <td width="58" style="width:.6in;border-top:none;border-left:none;border-bottom:
 solid black 1.0pt;mso-border-bottom-themecolor:text1;border-right:solid black 1.0pt;
 mso-border-right-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="60" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid black 1.0pt;mso-border-bottom-themecolor:text1;border-right:solid black 1.0pt;
 mso-border-right-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 0<o:p></o:p>
 15<o:p></o:p>
 30<o:p></o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> 6</o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="108" valign="top" style="width:81.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 </tr>
 <tr>
 <td width="43" style="width:.45in;border:solid black 1.0pt;mso-border-themecolor:
 text1;border-top:none;mso-border-top-alt:solid black .5pt;mso-border-top-themecolor:
 text1;mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:
 0in 5.4pt 0in 5.4pt">
 6<o:p></o:p>
 </td>
 <td width="176" valign="top" style="width:132.3pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Status mental :<o:p></o:p>
 <p class="MsoListParagraphCxSpFirst" style="margin-top:0in;margin-right:0in;
 margin-bottom:0in;margin-left:.3in;margin-bottom:.0001pt;mso-add-space:auto;
 text-indent:-.25in;line-height:normal;mso-list:l0 level1 lfo1">-         
 Orientasi sesuai kemampuan diri<o:p></o:p>
 <p class="MsoListParagraphCxSpLast" style="margin-top:0in;margin-right:0in;
 margin-bottom:0in;margin-left:.3in;margin-bottom:.0001pt;mso-add-space:auto;
 text-indent:-.25in;line-height:normal;mso-list:l0 level1 lfo1">-         
 Lupa akan keterbatasan diri<o:p></o:p>
 </td>
 <td width="58" style="width:.6in;border-top:none;border-left:none;border-bottom:
 solid black 1.0pt;mso-border-bottom-themecolor:text1;border-right:solid black 1.0pt;
 mso-border-right-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="60" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid black 1.0pt;mso-border-bottom-themecolor:text1;border-right:solid black 1.0pt;
 mso-border-right-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 0<o:p></o:p>
 15<o:p></o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> 2</o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="108" valign="top" style="width:81.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 </tr>
 <tr>
 <td width="337" colspan="4" style="width:252.9pt;border:solid black 1.0pt;
 mso-border-themecolor:text1;border-top:none;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Total<o:p></o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> 26</o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="108" valign="top" style="width:81.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:8;mso-yfti-lastrow:yes;height:51.25pt">
 <td width="337" colspan="4" style="width:252.9pt;border:solid black 1.0pt;
 mso-border-themecolor:text1;border-top:none;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt;height:51.25pt">
 Nama dan paraf yang melakukan penilaian<o:p></o:p>
 (unit terkait)<o:p></o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt;height:51.25pt">
 <o:p> </o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt;height:51.25pt">
 <o:p> </o:p>
 </td>
 <td width="114" valign="top" style="width:85.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt;height:51.25pt">
 <o:p> </o:p>
 </td>
 <td width="108" valign="top" style="width:81.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt;height:51.25pt">
 <o:p> </o:p>
 </td>
 </tr>
</tbody><tbody></tbody></table><table class="MsoTableGrid" border="1" cellspacing="0" cellpadding="0" style="border: none;">
 <tbody><tr>
 <td width="97" valign="top" style="width:72.9pt;border:solid black 1.0pt;
 mso-border-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Total Skor<o:p></o:p>
 </td>
 <td width="204" valign="top" style="width:153.0pt;border:solid black 1.0pt;
 mso-border-themecolor:text1;border-left:none;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Keterangan Tingkat Risiko<o:p></o:p>
 </td>
 <td width="348" valign="top" style="width:261.0pt;border:solid black 1.0pt;
 mso-border-themecolor:text1;border-left:none;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Pencegahan Risiko Jatuh<o:p></o:p>
 </td>
 </tr>
 <tr>
 <td width="97" valign="top" style="width:72.9pt;border:solid black 1.0pt;
 mso-border-themecolor:text1;border-top:none;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Skor 0 – 24<o:p></o:p>
 </td>
 <td width="204" valign="top" style="width:153.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Tidak ada risiko jatuh<o:p></o:p>
 </td>
 <td width="348" valign="top" style="width:261.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Perawatan baik<o:p></o:p>
 </td>
 </tr>
 <tr>
 <td width="97" valign="top" style="width:72.9pt;border:solid black 1.0pt;
 mso-border-themecolor:text1;border-top:none;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Skor 25 – 50<o:p></o:p>
 </td>
 <td width="204" valign="top" style="width:153.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Risiko rendah untuk jatuh<o:p></o:p>
 </td>
 <td width="348" valign="top" style="width:261.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Intervensi jatuh standar<o:p></o:p>
 </td>
 </tr>
 <tr>
 <td width="97" valign="top" style="width:72.9pt;border:solid black 1.0pt;
 mso-border-themecolor:text1;border-top:none;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Skor >= 51<o:p></o:p>
 </td>
 <td width="204" valign="top" style="width:153.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Risiko tinggi untuk jatuh<o:p></o:p>
 </td>
 <td width="348" valign="top" style="width:261.0pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Intervensi jatuh standar + intervensi risiko jatuh tinggi<o:p></o:p>
 </td>
 </tr>
</tbody></table>

Tempat TTD

Tanggal TTD

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