PEMERINTAHAN KABUPATEN SERANG

DINAS KESEHATAN
UPT PUSKESMAS KRAGILAN
JL. RAYA JAKARTA – SERANG KM.15 NO.83 KRAGILAN SERANG KODE POS : 42184
E-Mail : puskesmaskragilan@gmail.com

FORMULIR KOMUNIKASI EFEKTIF SBAR

(Situation, Background, Assesment, Recommendation)

Ruangan :
No.RM :
Tanggal masuk :

S Nama Pasien

Umur
: ..........................................................................
:
: ................................... :
DPJP : ...................................:
Situation
Diagnosis masuk : .....................................................
Keluhan saat ini : .....................................................

B
Riw. Penyakit dahulu : .....................................................
 Alergi : .....................................................
Terapi dari DPJP : .....................................................
........................................................
Background ........................................................

A
Kesadaran : ......................................................
TD : ......................................................
Nadi : ......................................................

 Assesment Nafas : ......................................................

Suhu : ......................................................

Tindakan (Asuhan Keperawatan) yang sudah dilakukan :

R Intruksi/order Dokter :

Recommendation

Tanggal/jam Yang melapor Yang menerima laporan Saksi

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READ BACK
Tanggal : ........................... Tanggal : ............................
Jam : ........................... Jam : ............................
Pemberi Instruksi Pemberi Instruksi

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