SBAR

RM.
8a
FORMULIR KOMUNIKASI EFEKTIF ATAU SERAH TERIMA PASIEN
NO. MR : ...............................................................
Nama : ...............................................................
Tgl Lahir : ...............................................................
Jam masuk : ...............................................................
Serah Terima Laporan Via Telp **)  Serah Terima  Laporan Via Telp **)
Tanggal : ........................................................... Tanggal : ...........................................................
SITUASION
S
Jam : ........................................................... Jam : ...........................................................
Nama Petugas : ........................................................... Nama Petugas : ...........................................................
Ruangan : ........................................................... Ruangan : ...........................................................
Keluhan Utama : .............................................................. Keluhan Utama : ..............................................................
.......................................................................................... ..........................................................................................
Diagnosa : ....................................................................... Diagnosa : .......................................................................

Tingkat Kesadaran ...........GCS : E.......... M.......... V........ Tingkat Kesadaran ...........GCS : E.......... M.......... V........
TANDA-TANDA Vital : TANDA-TANDA Vital :
TD : ...................mmHg HR : ...............................x/mnt TD : ...................mmHg HR : ...............................x/mnt
RR : ...................x/mnt T : .............oc Spo2 : ..........% RR : ...................x/mnt T : .............oc Spo2 : ..........%
Oksigenasi Terpasang : ........................................It/mnt Oksigenasi Terpasang : ........................................It/mnt
Diet : Diet :
Oral : Jenis ........................... Frekuensi : ................/hari Oral : Jenis ........................... Frekuensi : ................/hari
NGT/OGT : ........................... Frekuensi : .............../hari NGT/OGT : ........................... Frekuensi : .............../hari
BACKGROUND
B Infus : .............................................................................
Alat yang terpasang :

1.......................... 2....................... 3............................
Infus : .............................................................................
Alat yang terpasang :

1.......................... 2....................... 3............................
Therapi : Therapi :
1. ................................... 3.............................................. 1. ................................... 3..............................................
2 .................................... 4.............................................. 2 .................................... 4..............................................
Diagnostik : Diagnostik :
Torax : .............................. lbr USG : .......................... lbr Torax : .............................. lbr USG : .......................... lbr
EKG : .............................. lbr ........................................ EKG : .............................. lbr ........................................
........................................................................................ ........................................................................................
Hasil Lab Abnormal : Hasil Lab Abnormal :
1. ................................... 3.............................................. 1. ................................... 3..............................................
2 .................................... 4.............................................. 2 .................................... 4..............................................
TULISKAN ANALISA HASIL PENGKAJIAN : TULISKAN ANALISA HASIL PENGKAJIAN :
ASESMENT
**) Beri tnda √ pada pilihan

Ceklist bila sudah dilakukan (Lengkap laporan via telpon)** Ceklist bila sudah dilakukan (Lengkap laporan via telpon)**
T 1. ................................. 4. .................................... T 1. ................................. 4. ....................................
2. ................................. 5. .................................... 2. ................................. 5. ....................................
RECOMENDATION
3. ................................. 6. .................................... 3. ................................. 6. ....................................
B B
Bacakan Kembali Advis/saran Bacakan Kembali Advis/saran
R
a a
K Konfirmasi ulang dengan menanyakan ‘Benar?’ K Konfirmasi ulang dengan menanyakan ‘Benar?’
Petugas yang Dokter Petugas yang Dokter
Menyerahkan/melaporkan Menyerahkan/melaporkan

FORMULIR KOMUNIKASI EFEKTIF ATAU SERAH TERIMA PASIEN
 Serah Terima  Laporan Via Telp **)  Serah Terima  Laporan Via Telp **)
Tanggal : ........................................................... Tanggal : ...........................................................
SITUASION
Jam : ........................................................... Jam : ...........................................................
S Nama Petugas : ...........................................................

Ruangan : ...........................................................
Keluhan Utama : ...........................................................
.........................................................................................
Nama Petugas : ...........................................................
Ruangan : ...........................................................
Keluhan Utama : ...........................................................
.........................................................................................
Diagnosa : ....................................................................... Diagnosa : .......................................................................

Tingkat Kesadaran ...........GCS : E.......... M.......... V........ Tingkat Kesadaran ...........GCS : E.......... M.......... V........
TANDA-TANDA Vital : TANDA-TANDA Vital :
TD : ...................mmHg HR : ...............................x/mnt TD : ...................mmHg HR : ...............................x/mnt
RR : ...................x/mnt T : .............oc Spo2 : ..........% RR : ...................x/mnt T : .............oc Spo2 : ..........%
Oksigenasi Terpasang : ........................................It/mnt Oksigenasi Terpasang : ........................................It/mnt
Diet : Diet :
Oral : Jenis ........................... Frekuensi : ................/hari Oral : Jenis ........................... Frekuensi : ................/hari
NGT/OGT : ........................... Frekuensi : .............../hari NGT/OGT : ........................... Frekuensi : .............../hari
BACKGROUND
Infus : .............................................................................
B
Infus : .............................................................................
Alat yang terpasang : Alat yang terpasang :

1.......................... 2....................... 3............................ 1.......................... 2....................... 3............................
Therapi : Therapi :
1. ................................... 3.............................................. 1. ................................... 3..............................................
2 .................................... 4.............................................. 2 .................................... 4..............................................
Diagnostik : Diagnostik :
Torax : .............................. lbr USG : .......................... lbr Torax : .............................. lbr USG : .......................... lbr
EKG : .............................. lbr ........................................ EKG : .............................. lbr ........................................
........................................................................................ ........................................................................................
Hasil Lab Abnormal : Hasil Lab Abnormal :
1. ................................... 3.............................................. 1. ................................... 3..............................................
2 .................................... 4.............................................. 2 .................................... 4..............................................
TULISKAN ANALISA HASIL PENGKAJIAN : TULISKAN ANALISA HASIL PENGKAJIAN :
ASESMENT

Ceklist bila sudah dilakukan (Lengkap laporan via telpon)** Ceklist bila sudah dilakukan (Lengkap laporan via telpon)**
T T
1. ................................. 4. .................................... 1. ................................. 4. ....................................
2. ................................. 5. .................................... 2. ................................. 5. ....................................
RECOMENDATION 3. ................................. 6. .................................... 3. ................................. 6. ....................................
B B
R
Bacakan Kembali Advis/saran Bacakan Kembali Advis/saran
a a
K Konfirmasi ulang dengan menanyakan ‘Benar?’ K Konfirmasi ulang dengan menanyakan ‘Benar?’
Petugas yang Dokter Petugas yang Dokter
Menyerahkan/melaporkan Menyerahkan/melaporkan

SBAR

Diunggah oleh

Informasi Dokumen

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

SBAR

Diunggah oleh

Hak Cipta:

Format Tersedia

RM.

FORMULIR KOMUNIKASI EFEKTIF ATAU SERAH TERIMA PASIEN

Diagnosa : ....................................................................... Diagnosa : .......................................................................

Oksigenasi Terpasang : ........................................It/mnt Oksigenasi Terpasang : ........................................It/mnt

Alat yang terpasang :

Alat yang terpasang :

**) Beri tnda √ pada pilihan

**) Beri tnda √ pada pilihan

Jam : ........................................................... Jam : ...........................................................

S Nama Petugas : ...........................................................

Diagnosa : ....................................................................... Diagnosa : .......................................................................

Oksigenasi Terpasang : ........................................It/mnt Oksigenasi Terpasang : ........................................It/mnt

Alat yang terpasang : Alat yang terpasang :

**) Beri tnda √ pada pilihan

**) Beri tnda √ pada pilihan

Anda mungkin juga menyukai