CHECK LIST SUPERVISI HAND OVER

RUANGAN TANGGAL

OPERAN PAGI / SIANG / MALAM

NO ELEMEN YA TIDAK
1 Operan dilakukan tepat waktu Diawali dengan berdoa Dilakukan conference awal Oper
2 PPA diperkenalkan Dilakukan SBAR Instruksi medis dioperkan
3 Rencana tindakan selanjutnya dipaparkan
4 Masalah KDM diidentifikasi
Tanda tangan operan oleh dua belah pihak

5
6
7
8

9
10

Supervisor, / / 2023

( )
 FORMULIR SERAH TERIMA (HAND OVER) ANTAR SHIFT RUANG MARWAH
HARI, TANGGAL :.................................................................. Nama Pasien/Kamar : .................................................................
DPJP :................................................................. Tgl Lahir : ..................................................................
DIAGNOSA MEDIS :................................................................. No. RM : ..................................................................

PAGI SORE MALAM

SITUATION : Keluhan....................................................
...........................................................................................
..........................................................................................
BACKGROUND :
Kesadaran :.....................................GCS:.......................
SITUATION : Keluhan....................................................
...........................................................................................
..........................................................................................
BACKGROUND :
Kesadaran :.....................................GCS:........................
SITUATION : Keluhan....................................................
...........................................................................................
...........................................................................................
BACKGROUND :.............................................................
Kesadaran :.....................................GCS:...........................

TTV : TD:......................mmHg Nadi...........x/menit TTV : TD:......................mmHg Nadi...........x/menit TTV : TD:......................mmHg Nadi...........x/menit

Suhu :............oC RR:...........x/menit SpO2...........% Suhu :............oC RR:...........x/menit SpO2...........% Suhu :............oC RR:...........x/menit SpO2...........%

Oksigen:.............L/menit Infus...............tts/menit Oksigen:.............L/menit Infus...............tts/menit Oksigen:.............L/menit Infus...............tts/menit

Transfusi :............................| Katheter:Y/T | NGT: Y/T Transfusi :............................| Katheter:Y/T | NGT: Y/T Transfusi :...........................| Katheter:Y/T | NGT: Y/T
…………………………………………………………. …………………………………………………………. …………………………………………………………
ASSESMENT : Masalah Keperawatan............................ ASSESMENT : Masalah Keperawatan............................ ASSESMENT : Masalah Keperawatan............................
…………………………………………………………... …………………………………………………………... …………………………………………………………...

RECOMENDATION :................................................... RECOMENDATION :................................................... RECOMENDATION :...................................................

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

Pemberi Operan Penerima Operan Pemberi Operan Penerima Operan Pemberi Operan Penerima Operan
(...............................) (..............................) (...............................) (..............................) (...............................) (..............................)