RSK.

GINJAL RASYIDA Nama :

L/P
MEDAN Tgl Lahir :
Jl. D.I Panjaitan No. 144. Telp. (061) No. RM :
4151144, 4148722 - 4526225, Medan ( Mohon tempel label )
20119
Email : rsginjalrasyida@gmail.com

FORM SBAR SERAH TERIMA PASIEN

Tanggal : DINAS : PAGI/SORE/MALAM
Ruangan :

Keluhan: ...............................................................................
...............................................................................
S ITUATION Terapi /obat: ...............................................................................
Balance Cairan ...............................................................................
(Intake-Output): ...............................................................................
Hasil Pemeriksaan ...............................................................................
Penunjang: ...............................................................................
Diet Pasien: ...............................................................................
..............................................................................
Diagnosa: ...............................................................................
Riwayat: ...............................................................................
B ACKGROUND 1. R. penyakit dahulu: ...............................................................................
2. Obat yang telah ...............................................................................
dikonsumsi: ...............................................................................
3. Riwayat alergi: ...............................................................................
Keadaan Umum: ...............................................................................
Kesadaran: ...............................................................................
A SSESMENT Resiko yang dapat ...............................................................................
terjadi: ...............................................................................
...............................................................................
..............................................................................
Instruksi Dokter: ...............................................................................
Konsul: ...............................................................................
R ECOMENDA Rencana pemeriksaan: ...............................................................................
Observasi akhir: ...............................................................................
TION Hasil pemeriksaan: ...............................................................................
...............................................................................
Rencana tindakan: ...............................................................................
...............................................................................
.............................................................................
petugas yang menyerahkan petugas yang menerma

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