DRM.17/R.

I
RUMAH SAKIT TNI AL MERAUKE
JL.TRIKORA NO.7 NO. TELP (0971) 321512

KOMUNIKASI EFEKTIF MELALUI TELEPON

(SBAR)

Tanggal/Jam : ....................../............................

Nama saya:___________________dari ruangan__________________RSAL Merauke

SITTUATION :

 Saya menelepon tentang___________________________(nama

pasien,diagnosa,dan lokasi)

Pasien_______________________Umur_______Bed/Ruangan_____________
___

Diagnosa____________________________________

 Masalah yang ingin disampaikan.........................................................................

.........................................................................................................................

.........................................................................................................................

 Tanda-tanda vital (TD:_____/_____, N_____x/mnt, R_____x/mnt, SB_____x/mnt

 Tekanan darah lebih__________/dibawah________, Suhu

diatas________/dibawah________Respirasi_______________GCS

BACKGROUND/LATAR BELAKANG :

 Kapan MRS tanggal .........................................................................................

 Riwayat Penyakit Lain ......................................................................................

........................................................................................................................

 Komplikasi ........................................................................................................

ASSESMENT/PENILAIAN :

 Masalah yang dipikirkan adalah .........................................................................

........................................................................................................................

........................................................................................................................

 Masalah yang tampak adalah ...............................................................................

...........................................................................................................................
 ...........................................................................................................................
(sistem pencernaan, respirasi, cardiovaskular, saraf, dll)

 Pasien tampaknya tidak stabil dan cenderung memburuk, pasien memerlukan

tindakan segera

REKOMENDASI :

Apakah ada tambahan dari

DPJP...................................................................................

......................................................................................................................................

......................................................................................................................................

......................................................................................................................................

......................................................................................................................................

......................................................................................................................................

.......................................................................................................................................

 Pasien dapat ditransfer ke ruang ICU

 Dokter bisa datang melihat pasien

 Dokter dapat menjelaskan kondisi pasien kepada keluarga

Apakah diperlukan pemeriksaan tambahan:

 Rontgen___________________________________(foto thorax, dll)

 Laboratorium _______________________________(BJ plasma, dll)

 EKG

 USG

Jika ada perubahan tatalaksana, tanyakan :

 Seberapa sering perlu dilaporkan kondisi pasien ke

dokter........................................

 Menurut perkiraan dokter berapa lama kondisi pasien akan membaik

 Jika pasien tidak membaik apakah dokter ingin diberitahu/ditelepon lagi

Merauke,..........................................................

Pelapor Dokter Penanggung Jawab

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