No.

RM :
FORMULIR KOMUNIKASI Nama :
SBAR Tanggal Lahir :
Jam Masuk :
UPTD PUSKESMAS
NIBONG
Serah Terima Laporan Via Telfon Serah Terima Laporan Via Telfon
Tanggal :............................... Tanggal :...............................
SI Jam :............................... Jam :...............................

S
T Nama Petugas :............................... Nama Petugas :...............................
U Ruangan :............................... Ruangan :...............................
A Keluhan Utama :............................... Keluhan Utama :...............................
TI ..........................................................
..........................................................
O .......................................................... ..........................................................
N ......................................................... .........................................................
S

Diagnosa :............................................................ Diagnosa :............................................................

Tingkat Kesadaran .......GCS : E.....V......M........ Tingkat Kesadaran .......GCS : E......V........M........
Tanda-tanda vital : Tanda-tanda vital :
TD : ........mmhg HR :...........................x/mnt TD : ........mmhg HR :...........................x/mnt
RR :.........x/mnt T :............0CspO2................% RR :.........x/mnt T :..........0CspO2................%

Oksigen Terpasang.........................It/mnt Oksigen Terpasang.........................It/mnt

B
A Diet : Diet :
C Oral : Jenis.....Frekuansi.................../hari Oral : Jenis.....Frekuansi.................../hari
K NGT/OGT :..........Frekuansi............./hari NGT/OGT :..........Frekuansi............./hari
G

B R
O
U
Infus :.....................................................

Alat Yang Terpasang :

Infus :.....................................................

Alat Yang Terpasang :

N 1...............................................................
D Therapi :
1. .........................................................
2. .........................................................
Diagnostik :
Thorax...... ...lbr USG.......................lbr
EKG ............lbr....................................
Hasil lab Abnormal:
1. .......................................................
2. ........................................................
TULISKAN HASIL ANALISA PENGKAJIAN :
1..............................................................
Therapi :
1. ........................................................
2. ........................................................
Diagnostik :
Thorax...... ...lbr USG.......................lbr
EKG ............lbr....................................
Hasil lab Abnormal:
1. .......................................................
2. ........................................................
TULISKAN HASIL ANALISA PENGKAJIAN :

A
ASS
ES
ME
NT Ceklist bila sudah dilakukan (lengkap laporan via telfon Ceklist bila sudah dilakukan (lengkap laporan via telfon

( Tuliskan Advis/saran ) : ( Tuliskan Advis/saran ) :

R T 1. ...................................................... T 1. ......................................................
E 2. ....................................................... 2. .......................................................
C 3. ....................................................... 3. ............................... .......................
O B Bacakan Kembali Advis/saran B Bacakan Kembali Advis/saran
a a

R
M
K Konfirmasi ulang dengan menanyakan benar K Konfirmasi ulang dengan menanyakan benar
M
E
N Petugas yang Petugas yang menerima Petugas yang Petugas yang menerima
D menyerahkan/melaporkan laporan menyerahkan/melaporkan laporan
A
T
I
O TTD&Nama Jelas TTD&Nama Jelas TTD&Nama Jelas TTD&Nama Jelas
N