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1. Pengkajian spiritual pasien dilakukan tanggal.........................Jam......................

WIB
oleh.........................................
2. Keyakinan pasien terhadap Tuhan yang memotivasi kesembuhan pasien:
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3. Nilai-nilai hidup pasien:
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4. Tujuan Hidup Pasien:
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5. Kepercayaan Pasien:

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Tanggal / Jam selesai pengkajian


........................... / .................WIB

Nama Lengkap & Tandatangan

RM.RI. 20

RUMAH SAKIT BAPTIS BATU


Jl. Raya Tlekung No. 1 Tlekung Junrejo Batu
Telp. (0341) 594161 Fax. (0341) 598911

PENGKAJIAN SPIRITUAL
PASIEN
Nama :

No. Register :
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Umur :

Ruang :

Lantai :

No. Rekam Medik :


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RSBB 2013

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