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Format SBAR

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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63 views1 page

Format SBAR

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.

Uploaded by

sari
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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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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