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DISCHARGE PLANNING

Diagnosa

DPJP

Tanggal Masuk RS

Tanggal Dilakukan Rencana Pemulangan Pasien

Estimasi Tanggal Pemulangan Pasien

Usia Lanjut (>= 65 Tahun Atau Lebih)

Apakah pasien memerlukan alat bantu setelah keluar dari RS (tongkat, kursi, roda, walker, dll)?

Apakah memerlukan bantuan perawatan khusus di rumah setelah keluar dari RS (Homecare, home visit)?

Apakah pasien bermasalah dalam memenuhi kebutuhan pribadinya setelah keluar dari RS?

Apakah pasien memiliki nyeri kronis dan kelelahan setelah keluar dari RS?

Apakah pasien menggunakan peralatan medis di rumah setelah keluar dari RS (cateter, Oksigen, dll)?

Apakah pasien dan keluarga memerlukan keterampilan khusus setelah keluar dari RS?

Tahap I - Pasien Masuk

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 Fase<o:p></o:p>
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 Kegiatan<o:p></o:p>
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 Tanggal<o:p></o:p>
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 Jam<o:p></o:p>
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 Evaluasi<o:p></o:p>
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 Tahap I<o:p></o:p>
 Pasien Masuk<o:p></o:p>
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 1<img width="11" height="11" src="file:///C:\Users\USER\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif" v:shapes="_x0000_s1026"><o:p></o:p>
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 Pengkajian fisik dan psikososial<o:p></o:p>
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 <td width="90" valign="top" style="width:67.5pt;border-top:none;border-left:none;
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 <o:p> 13/1/2025</o:p>
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 <o:p> 14:00</o:p>
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 <o:p> </o:p>
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 2<img width="11" height="12" src="file:///C:\Users\USER\AppData\Local\Temp\msohtmlclip1\01\clip_image002.gif" v:shapes="_x0000_s1027"><o:p></o:p>
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 Pengkajian status fungsional<o:p></o:p>
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 text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>13/1/2025
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 <o:p> </o:p> 14:00
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 <td width="192" valign="top" style="width:2.0in;border-top:none;border-left:none;
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 <o:p> </o:p>
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 <td width="84" rowspan="8" valign="top" style="width:63.0pt;border-top:none;
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 3<img width="11" height="11" src="file:///C:\Users\USER\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif" v:shapes="_x0000_s1028"><o:p></o:p>
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 <td width="246" valign="top" style="width:184.5pt;border:none;border-right:solid black 1.0pt;
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 Pengkajian kebutuhan mengenai pendidikan kesehatan tentang :<o:p></o:p>
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 mso-border-alt:solid black .5pt;mso-border-themecolor:text1;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>13/1/2025
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 <td width="90" rowspan="8" valign="top" style="width:67.5pt;border-top:none;
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 <o:p> </o:p> 14:00
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 <td width="192" rowspan="8" valign="top" style="width:2.0in;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>
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 mso-border-left-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-right-alt:solid black .5pt;
 mso-border-right-themecolor:text1;padding:0in 5.4pt 0in 5.4pt">
       a.       Proses penyakit<o:p></o:p>
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 <td width="246" valign="top" style="width:184.5pt;border:none;border-right:solid black 1.0pt;
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 mso-border-right-themecolor:text1;padding:0in 5.4pt 0in 5.4pt">
       b.     
 Obat-obatan<o:p></o:p>
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       c.      
 Prosedur cara perawatan<o:p></o:p>
 </td>
 </tr>
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 <td width="246" valign="top" style="width:184.5pt;border:none;border-right:solid black 1.0pt;
 mso-border-right-themecolor:text1;mso-border-left-alt:solid black .5pt;
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 mso-border-left-themecolor:text1;mso-border-right-alt:solid black .5pt;
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       d.     
 Pencegahan faktor resiko<o:p></o:p>
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 mso-border-right-themecolor:text1;padding:0in 5.4pt 0in 5.4pt">
       e.     
 Lingkungan yang perlu dipersiapkan<o:p></o:p>
 </td>
 </tr>
 <tr>
 <td width="246" valign="top" style="width:184.5pt;border:none;border-right:solid black 1.0pt;
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 mso-border-left-themecolor:text1;mso-border-right-alt:solid black .5pt;
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       f.       
 Rencana tindaklanjut<o:p></o:p>
 </td>
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 <td width="246" valign="top" style="width:184.5pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
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 solid black .5pt;mso-border-left-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-bottom-alt:solid black .5pt;
 mso-border-bottom-themecolor:text1;mso-border-right-alt:solid black .5pt;
 mso-border-right-themecolor:text1;padding:0in 5.4pt 0in 5.4pt">
       g.      
 Support system<o:p></o:p>
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 4<img width="11" height="12" src="file:///C:\Users\USER\AppData\Local\Temp\msohtmlclip1\01\clip_image002.gif" v:shapes="_x0000_s1029"><o:p></o:p>
 </td>
 <td width="246" valign="top" style="width:184.5pt;border-top:none;border-left:
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 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
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 Pemahaman pasien keluarga terhadap penjelasan dari :<o:p></o:p>
 Fisioterapi<o:p></o:p>
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 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>13/1/2025
 </td>
 <td width="90" valign="top" style="width:67.5pt;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> 14:00
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 <td width="192" valign="top" style="width:2.0in;border-top:none;border-left:none;
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 <o:p> </o:p>
 </td>
 </tr><tr><td width="84" valign="top" style="width:63.0pt;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:52.6pt">5</td><td width="246" valign="top" style="width:184.5pt;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:52.6pt">Ahli Gizi</td><td width="90" valign="top" style="width:67.5pt;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:52.6pt">13/1/2025</td><td width="90" valign="top" style="width:67.5pt;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:52.6pt"> 14:00</td><td width="192" valign="top" style="width:2.0in;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:52.6pt"> </td></tr>
</tbody></table>

Tahap II

<table class="MsoTableGrid" border="1" cellspacing="0" cellpadding="0" style="border: none;">
 <tbody><tr>
 <td width="85" rowspan="8" style="width:63.9pt;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">
 Tahap II<o:p></o:p>
 </td>
 <td width="30" valign="top" style="width:22.5pt;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">
 <o:p> 1</o:p>
 </td>
 <td width="276" valign="top" style="width:207.0pt;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">
 Pendidikan kesehatan tentang proses penyakit<o:p></o:p>
       a.       Pengertian,
 penyebab, tanda dan gejala<o:p></o:p>
       b.      Faktor
 resiko<o:p></o:p>
       c.       Komplikasi<o:p></o:p>
 </td>
 <td width="84" valign="top" style="width:63.0pt;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">
 <o:p> </o:p>
 </td>
 <td width="57" valign="top" style="width:42.6pt;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">
 <o:p> </o:p> 14:00
 </td>
 <td width="87" valign="top" style="width:65.4pt;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">
 <o:p> </o:p>
 </td>
 </tr>
 <tr>
 <td width="30" valign="top" style="width:22.5pt;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="276" valign="top" style="width:207.0pt;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">
 Pendidikan kesehatan tentang obat-obatan<o:p></o:p>
 </td>
 <td width="84" valign="top" style="width:63.0pt;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>
 <td width="57" valign="top" style="width:42.6pt;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> 14:00
 </td>
 <td width="87" valign="top" style="width:65.4pt;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="30" valign="top" style="width:22.5pt;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="276" valign="top" style="width:207.0pt;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">
 Pendidikan kesehatan tentang penatalaksanaan<o:p></o:p>
 </td>
 <td width="84" valign="top" style="width:63.0pt;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>
 <td width="57" valign="top" style="width:42.6pt;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> 14:00
 </td>
 <td width="87" valign="top" style="width:65.4pt;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="30" valign="top" style="width:22.5pt;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> 4</o:p>
 </td>
 <td width="276" valign="top" style="width:207.0pt;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">
 Pendidikan kesehatan tentang pemeriksaan diagnostic<o:p></o:p>
 </td>
 <td width="84" valign="top" style="width:63.0pt;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>
 <td width="57" valign="top" style="width:42.6pt;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> 14:00
 </td>
 <td width="87" valign="top" style="width:65.4pt;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="30" valign="top" style="width:22.5pt;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="276" valign="top" style="width:207.0pt;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">
 Pendidikan kesehatan tentang rehabilitasi<o:p></o:p>
 </td>
 <td width="84" valign="top" style="width:63.0pt;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>
 <td width="57" valign="top" style="width:42.6pt;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> 14:00
 </td>
 <td width="87" valign="top" style="width:65.4pt;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="30" valign="top" style="width:22.5pt;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="276" valign="top" style="width:207.0pt;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">
 Pendidikan kesehatan tentang perawatan dalam hygiene personal<o:p></o:p>
 </td>
 <td width="84" valign="top" style="width:63.0pt;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>
 <td width="57" valign="top" style="width:42.6pt;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> 14:00
 </td>
 <td width="87" valign="top" style="width:65.4pt;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="30" valign="top" style="width:22.5pt;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> 7</o:p>
 </td>
 <td width="276" valign="top" style="width:207.0pt;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">
 Pendidikan kesehatan tentang perubahan posisi<o:p></o:p>
 </td>
 <td width="84" valign="top" style="width:63.0pt;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>
 <td width="57" valign="top" style="width:42.6pt;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> 14:00
 </td>
 <td width="87" valign="top" style="width:65.4pt;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="30" valign="top" style="width:22.5pt;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> 8</o:p>
 </td>
 <td width="276" valign="top" style="width:207.0pt;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">
 Pendidikan kesehatan tentang pencegahan jatuh<o:p></o:p>
 </td>
 <td width="84" valign="top" style="width:63.0pt;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>
 <td width="57" valign="top" style="width:42.6pt;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> 14:00
 </td>
 <td width="87" valign="top" style="width:65.4pt;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>
</tbody></table>

Tahap III

<table class="MsoTableGrid" border="1" cellspacing="0" cellpadding="0" style="border: none;">
 <tbody><tr>
 <td width="85" rowspan="8" style="width:63.9pt;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">
 Tahap III<o:p></o:p>
 </td>
 <td width="24" valign="top" style="width:.25in;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">
 <o:p> 1</o:p>
 </td>
 <td width="276" valign="top" style="width:207.0pt;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">
 Pendidikan kesehatan tentang modifikasi gaya hidup<o:p></o:p>
       a.       Pengaturan
 diet (sesuai faktor resiko)<o:p></o:p>
       b.      Aktifitas
 fisik<o:p></o:p>
       c.       Merokok<o:p></o:p>
       d.      Penggunaan
 alcohol dan obat-obatan<o:p></o:p>
 </td>
 <td width="90" valign="top" style="width:67.5pt;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">
 <o:p> </o:p>
 </td>
 <td width="96" valign="top" style="width:1.0in;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">
 <o:p> </o:p>
 </td>
 </tr>
 <tr>
 <td width="24" valign="top" style="width:.25in;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="276" valign="top" style="width:207.0pt;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">
 Diskusi tentang modifikasi lengkungan pasien setelah pulang dari
 rumah sakit<o:p></o:p>
 </td>
 <td width="90" valign="top" style="width:67.5pt;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="96" valign="top" style="width:1.0in;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="24" valign="top" style="width:.25in;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="276" valign="top" style="width:207.0pt;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">
 Pendidikan kesehatan tentang cara perawatan luka<o:p></o:p>
 </td>
 <td width="90" valign="top" style="width:67.5pt;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="96" valign="top" style="width:1.0in;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="24" valign="top" style="width:.25in;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> 4</o:p>
 </td>
 <td width="276" valign="top" style="width:207.0pt;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">
 Diskusikan tentang cara perawatan lanjutan<o:p></o:p>
 - Pasien<o:p></o:p>
 - Bantuan ADL<o:p></o:p>
 - Jadwal kontrol<o:p></o:p>
 </td>
 <td width="90" valign="top" style="width:67.5pt;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="96" valign="top" style="width:1.0in;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="24" valign="top" style="width:.25in;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="276" valign="top" style="width:207.0pt;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>
 <td width="90" valign="top" style="width:67.5pt;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="96" valign="top" style="width:1.0in;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="24" valign="top" style="width:.25in;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="276" valign="top" style="width:207.0pt;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>
 <td width="90" valign="top" style="width:67.5pt;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="96" valign="top" style="width:1.0in;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="24" valign="top" style="width:.25in;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="276" valign="top" style="width:207.0pt;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>
 <td width="90" valign="top" style="width:67.5pt;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="96" valign="top" style="width:1.0in;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="24" valign="top" style="width:.25in;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="276" valign="top" style="width:207.0pt;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>
 <td width="90" valign="top" style="width:67.5pt;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="96" valign="top" style="width:1.0in;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>
</tbody></table>

Tahap IV

<table class="MsoTableGrid" border="1" cellspacing="0" cellpadding="0" style="border: none;">
 <tbody><tr>
 <td width="106" rowspan="2" style="width:79.8pt;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">
 Tahap IV<o:p></o:p>
 </td>
 <td width="27" valign="top" style="width:20.1pt;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">
 <o:p> </o:p>
 </td>
 <td width="258" valign="top" style="width:193.5pt;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">
 Diskusi tentang pengawasan pada pasien setelah pulang tentang obat,
 diet, aktivitas dan peningkatan status fungsional<o:p></o:p>
 </td>
 <td width="90" valign="top" style="width:67.5pt;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">
 <o:p> </o:p>
 </td>
 <td width="51" valign="top" style="width:38.1pt;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">
 <o:p> </o:p>
 </td>
 <td width="106" valign="top" style="width:79.8pt;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">
 <o:p> </o:p>
 </td>
 </tr>
 <tr>
 <td width="27" valign="top" style="width:20.1pt;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="258" valign="top" style="width:193.5pt;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">
 Diskusi tentang support system keluarga, financial, dan alat
 transportasi yang akan digunakan pasien<o:p></o:p>
 </td>
 <td width="90" valign="top" style="width:67.5pt;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="51" valign="top" style="width:38.1pt;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="106" valign="top" style="width:79.8pt;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>
</tbody></table>

Catatan Pulang

<table class="MsoTableGrid" border="1" cellspacing="0" cellpadding="0" style="border: none;">
 <tbody><tr>
 <td width="294" colspan="2" rowspan="3" valign="top" style="width:220.25pt;
 border:solid windowtext 1.0pt;mso-border-alt:solid windowtext .5pt;
 padding:0in 5.4pt 0in 5.4pt">
 Catatan Pulang<o:p></o:p>
 </td>
 <td width="142" colspan="2" style="width:106.7pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 Pelaksanaan<o:p></o:p>
 </td>
 <td width="165" colspan="3" rowspan="2" valign="top" style="width:123.85pt;
 border:solid windowtext 1.0pt;border-left:none;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 Keterangan<o:p></o:p>
 </td>
 </tr>
 <tr>
 <td width="142" colspan="2" style="width:106.7pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 Sudah Diberikan<o:p></o:p>
 </td>
 </tr>
 <tr>
 <td width="72" style="width:.75in;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 Tanggal<o:p></o:p>
 </td>
 <td width="70" style="width:52.7pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 Jam<o:p></o:p>
 </td>
 <td width="56" style="width:41.7pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 PBJ<o:p></o:p>
 </td>
 <td width="53" style="width:39.85pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 PAPS<o:p></o:p>
 </td>
 <td width="56" style="width:42.3pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 EXITUS<o:p></o:p>
 </td>
 </tr>
 <tr>
 <td width="23" valign="top" style="width:17.6pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="270" valign="top" style="width:202.65pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 Obat-obatan
 pulang<o:p></o:p>
 </td>
 <td width="72" style="width:.75in;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="70" style="width:52.7pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="56" style="width:41.7pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="53" style="width:39.85pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="56" style="width:42.3pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 </tr>
 <tr>
 <td width="23" valign="top" style="width:17.6pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="270" valign="top" style="width:202.65pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 Surat Kontrol<o:p></o:p>
 </td>
 <td width="72" style="width:.75in;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="70" style="width:52.7pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="56" style="width:41.7pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="53" style="width:39.85pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="56" style="width:42.3pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 </tr>
 <tr>
 <td width="23" valign="top" style="width:17.6pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="270" valign="top" style="width:202.65pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 Rujukan
 Rehabilitasi<o:p></o:p>
 </td>
 <td width="72" style="width:.75in;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="70" style="width:52.7pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="56" style="width:41.7pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="53" style="width:39.85pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 <td width="56" style="width:42.3pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
 <o:p> </o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:6;mso-yfti-lastrow:yes;height:109.75pt">
 <td width="23" valign="top" style="width:17.6pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0in 5.4pt 0in 5.4pt;height:109.75pt">
 <o:p> </o:p>
 </td>
 <td width="270" valign="top" style="width:202.65pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:109.75pt">
 Perawat<o:p></o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 (Nama dan Tanda Tangan)<o:p></o:p>
 </td>
 <td width="307" colspan="5" valign="top" style="width:230.55pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:109.75pt">
 Pasien/ Keluarga<o:p></o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 (Nama dan Tanda Tangan)<o:p></o:p>
 </td>
 </tr>
</tbody></table>

Tempat TTD

Tanggal TTD

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