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    Format SBAR

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    1. The document is a form for effective communication or patient handover via telephone. 2. It includes sections for patient situation, background, assessment, and recommendation. 3. The form is used to document key details like vital signs, diagnosis, treatment, and advice during a telephone call handover of patient care between medical staff.

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    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd

    Format SBAR

    Uploaded by

    sari
    30 views1 page
    1. The document is a form for effective communication or patient handover via telephone. 2. It includes sections for patient situation, background, assessment, and recommendation. 3. The form is used to document key details like vital signs, diagnosis, treatment, and advice during a telephone call handover of patient care between medical staff.

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    LEMBAR SBAR

    Original Title

    Copy of Format SBAR

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    © © All Rights Reserved

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    1. The document is a form for effective communication or patient handover via telephone. 2. It includes sections for patient situation, background, assessment, and recommendation. 3. The form is used to document key details like vital signs, diagnosis, treatment, and advice during a telephone call handover of patient care between medical staff.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Download as xls, pdf, or txt
    30 views1 page

    Format SBAR

    Uploaded by

    sari
    1. The document is a form for effective communication or patient handover via telephone. 2. It includes sections for patient situation, background, assessment, and recommendation. 3. The form is used to document key details like vital signs, diagnosis, treatment, and advice during a telephone call handover of patient care between medical staff.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Download as xls, pdf, or txt
    of 1

    NO.

    MR : ……………………………………………
    FORMULIR KOMUNIKASI EFEKTIF ATAU SERAH NAMA : ……………………………………………
    TERIMA PASIEN VIA TELPON Tgl Lahir : ……………………………………………
    Jam Masuk : ……………………………………………

    Serah Terima Laporan Via Telp**) Serah Terima Laporan Via Telp**)
    Tanggal : …………………………………………… Tanggal : ……………………………………………
    SITUATION

    Jam : …………………………………………… Jam : ……………………………………………


    S Dokter/Perawat/Bidan
    Ruangan
    : ……………………………………………
    : ……………………………………………
    Dokter/Perawat/Bidan
    Ruangan
    : ……………………………………………
    : ……………………………………………
    Keluhan Utama : …………………………………………… Keluhan Utama : ……………………………………………
    …………………………………………………………………………………….. ……………………………………………………………………………………..
    Diagnosa : ……………………………………………………………………. Diagnosa : …………………………………………………………………….
    Tingkat Kesadaran…….. GCS: E …....…M …….… V …….… Tingkat Kesadaran…….. GCS: E …....…M …….… V …….…
    Tanda-tanda Vital: Tanda-tanda Vital:
    TD: ………………………mmHg HR: ………………………x/mnt TD: ………………………mmHg HR: ………………………x/mnt
    RR: ………………………x/mnt T: ………… oC SpO2:……..% RR: ………………………x/mnt T: ………… oC SpO2:……..%
    Oksigenasi Terpasang : …………………………………..lt/mnt Oksigenasi Terpasang : …………………………………..lt/mnt
    Diet: Diet:
    Oral : Jenis ……………………………. Frekuensi: ………../hari Oral : Jenis ……………………………. Frekuensi: ………../hari
    NGT/OGT : ………………… …………. Frekuensi: ………../hari NGT/OGT : ………………… …………. Frekuensi: ………../hari
    Infus : ………………………………………………………………………… Infus : …………………………………………………………………………
    BACKROUND

    B Alat yang terpasang:


    1. …………………….. 2. ………………………… 3. …………………….
    Alat yang terpasang:
    1. …………………….. 2. ………………………… 3. …………………….
    Therapi: Therapi:
    1. …………………………. 3. …………………………. 1. …………………………. 3. ………………………….
    2. …………………………. 4. …………………………. 2. …………………………. 4. ………………………….
    Diagnostik: Diagnostik:
    Thorax: ……………………….lbr USG: ……………………….lbr Thorax: ……………………….lbr USG: ……………………….lbr
    EKG: ……………………….lbr …………………………………………… EKG: ……………………….lbr ……………………………………………
    ……………………………………………………………………………………. …………………………………………………………………………………….
    Hasil Lab Abnormal: Hasil Lab Abnormal:
    1. …………………………. 3. …………………………. 1. …………………………. 3. ………………………….
    2. …………………………. 4. …………………………. 2. …………………………. 4. ………………………….
    TULISKAN ANALISA HASIL PENGKAJIAN: TULISKAN ANALISA HASIL PENGKAJIAN:
    ASSESMENT

    Ceklis bila sudah dilakukan (lengkap laporan via telpon)** Ceklis bila sudah dilakukan (lengkap laporan via telpon)**
    (Tulisakan Advis/saran): (Tulisakan Advis/saran):
    1. ……………… 4. ……………… 1. ……………… 4. ………………
    T T
    2. ……………… 5. ……………… 2. ……………… 5. ………………
    3. ……………… 6. ……………… 3. ……………… 6. ………………
    RECOMMENDATION

    B Bacakan Kembali Advis/saran B Bacakan Kembali Advis/saran


    a a
    R K Konfirmasi ulang dengan
    menanyakan 'benar?'
    K Konfirmasi ulang dengan
    menanyakan 'benar?'
    Petugas yang Menerima/ Petugas yang Petugas yang Menerima/ Petugas yang
    menerima laporan menerima/menerima laporan menerima laporan menerima/menerima laporan

    TTD & Nama Jelas TTD & Nama Jelas TTD & Nama Jelas TTD & Nama Jelas

    **) Beri tanda ✔ pada pilihan

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