**)

FORMULIR KOMUNIKASI EFEKTIF DENGAN FASILITAS RUJUKAN Beri

tanda
√
pada

Serah Terima Laporan Via Telp **)

SITUATION

s Tanggal
Jam
: ….............................................................................................................................................
: ……………………….............................................................................................................
Nama Petugas : ……………………….............................................................................................................
Ruangan : ………………………….........................................................................................................
Keluhan Utama : ……………………….................................................................................................….........
Keadaan Umum : ....................................................................................................................................................
Kesadaran : ..................................................................GCS: ..................................................................................
Tanda-tanda Vital :
TD : ……….................…mmHg. HR : ..................................x/mnt
RR : ……..................……x/mnt. T : …........................…....oC SpO2.........................%
Antoprometri : BB :................KG TB :...................................CM
Pemeriksaan Fisik :
Kepala/Leher : .....................................................................................................................................................

B Thorax : ...............................................................................................................................................................
BACKGROUND

Abdomen :............................................................................................................................................................
Extremitas :..........................................................................................................................................................
Oksigenasi Terpasang :..............................................................................................................................liter/mnt
Diet :........................................................................................................................................................................
Alat yang terpasang : ..............................................................................................................................................

Therapi:
1. ………………….........................................................................................................................................
2. …………………………….........................................................................................................................
3. ………………………………..................................................…...............................................................
4. .....................................................................................................................................................................
Diagnostik Penunjang : .............................................................................................................................................

TULISKAN ANALISA HASIL PENGKAJIAN :

ASSESMENT

Ceklist bila sudah dilakukan (lengkap laporan via telpon)**

(Tuliskan Advis/saran) :
1. ..............................................................................................................................................................
T 2. ..............................................................................................................................................................
R
RECOMENDATION

3. ..............................................................................................................................................................
4. ..............................................................................................................................................................
B Bacakan Kembali Advis/saran
a
K Konfirmasi ulang dengan menanyakan ‘Benar?’
Petugas yang menyerahkan/melaporkan Petugas yang menerima/menerima laporan

TTD & Nama Jelas

TTD & Nama Jelas
pilihan