No.

Rekam Medis :
DINAS KESEHATAN
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UPTD PUSKESMAS ONE WAARA KEC. LAKUDO
Jln. Poros Wamengkoli Desa One Waara Kode Pos 93763
Nama Lengkap Pasien :
Email: puskesmasonewaara01@gmail.com ……………………………………………................................
tgl/bln/thn lahir :
……………………………………………................................
BPJS :
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FORMULIR SBAR
Situation, Background, Assesment, Recommendation

S
Pelapor : ............................................ Penerima laporan:....................................
Nama Pasien : …......................................... Alamat : …………………….
Umur : ............................................. Nomor RM : …………………….
Keluhan saat ini : ............................................. Diagnosis masuk : ..................................

Situation

Riw. Penyakit : ...................................................................................

B
Dahulu ....................................................................................

Riw. Alergi : ....................................................................................

Riw. Penggunaan Obat: ....................................................................................

Background

Kesadaran : …......................................... Hasil Lab:......................................

A
TD : .............................................
Nadi : .............................................
Nafas : .............................................X-Ray : ......................................
Suhu : .............................................
Pemfis : .............................................USG : .......................................
Assesment

R
Tindakan yang sudah
dilakukan: ................................................................................................................
..................................................................................................................................
..................

Instruksi
Recommend Dokter: .....................................................................................................................
ation ..................................................................................................................................

Tangal/Jam: Yang Melapor Yang Menerima

……………. Laporan

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