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Lampiran 3

RUMAH SAKIT
AT-TUROTS AL-ISLAMY
Klaci I Margoluwih Seyegan Sleman Yogyakarta (0274) 7114823, 7431668
FORM PERENCANAAN EDUKASI INDIVIDU PASIEN DAN KELUARGA
RAWAT INAP
NAMA PASIEN
NO. CM

NO.

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RUANG
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DIAGNOSA :

UNIT / PETUGAS YANG BERSANGKUTAN

TANDA TANGAN
DAN NAMA
TERANG

1.

DOKTER :..............................................................
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5

PERAWAT /BIDAN:.............................................
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FISIOTERAPI :....................................................
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AHLI GIZI :............................................................
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FARMASI :...........................................................
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Lampiran 4
RUMAH SAKIT
AT-TUROTS AL-ISLAMY
Klaci I Margoluwih Seyegan Sleman Yogyakarta (0274) 7114823, 7431668
FORM DOKUMENTASI EDUKASI INDIVIDU PASIEN DAN KELUARGA RAWAT
INAP

NAMA PASIEN
NO. CM
DIAGNOSA
Material edukasi :

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:
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Leaflet

RUANG
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HARI & TGL.:
JAM
:
Booklet

Lembar balik

Audiovisual

Materi : ......................................................................................................................
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Pertanyaan :.............................................................................................................
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Tingkat pemahaman pasien/keluarga :
pasien/keluarga dapat menjelaskan ulang materi dengan baik
pasien/keluarga dapat menjelaskan ulang materi kurang lengkap
pasien/keluarga tidak dapat menjelaskan ulang materi
Evaluasi :

Re-Edukasi

Re-demonstrasi

Sudah mengerti

Penyuluh

Pasien/keluarga

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