PEMERINTAH KABUPATEN JEMBER

DINAS KESEHATAN
UPT PUSKESMAS SUKOWONO
JL. A Yani no. 102 Sukowono Telp 0331-566168
Kode Pos 68194

FORMULIR SBAR
(Situation, Background, Assesment, Recommendation)
Nama Pasien : ....................................... Ruangan : .......................................

S Umur
DPJP
: ........................................
: ........................................
Nomor MR : .......................................
Tanggal Masuk : ............................................
Situation Diagnosa Masuk : .......................................................................................................................
Keluhan saat ini : .......................................................................................................................

Riw. Penyakit

B Dahulu
Alergi
: ......................................................................................................................
: .....................................................................................................................
Background Terapi dan DPJP : ......................................................................................................................

Kesadaran : .....................................................................................................................

A TD
Nadi
: .....................................................................................................................
: ......................................................................................................................
Assesment Nafas : ......................................................................................................................
Suhu : ......................................................................................................................

Tindakan (Asuhan Keperawatan yang sudah

R dilakukan) : .....................................................................................................................................................
........................................................................................................................................................................
Recomendation ...................
Instruksi Dokter : ...........................................................................................................................................
.......................................................................................................................................................................
.......................................................................................................................................................................

Tanggal/Jam Yang Melaporkan Yang Menerima Laporan Saksi

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

KONFIRMASI

SAYA TELAH MEMBACA SELURUH PERINTAH VIA LISAN/PHONE TANGGAL : ..................................................................

JAM : ............................ YANG TERTULIS DI DALAM CPPT DAN DENGAN INI SAYA MEMVERIFIKASI BAHWA ISI
PERINTAH ADALAH BENAR SESUAI DENGAN YANG DI PERINTAHKAN.

PEMBERI INSTRUKSI

dr.................................

NIP: