11. Formulir Permintaan Pelayanan Rohani

RUMAH SAKIT MARDI WALUYO METRO Jl. Jendral Sudirman No 156 Metro Telp (0725) 42512 PERMINTAAN PELAYANAN SPIRITUAL BERDASARKAN AGAMA DAN KEPERCAYAAN PASIEN

 Nama :........................................ :........................................ No MR : Tanggal Lahir:......................................... Lahir:......................................... Ruang/ Kelas : Saya yang bertanda tangan dibawah ini, ini,  Nama :............................................... :..................................................................... ........................... ..... Tanggal Lahir :............................................. :................................................................... ............................. ....... Alamat :............................................................................................................ .......................................... ................................................................ ............................................ ............................................ ........................ Dengan ini menyatakan dengan sesungguhnya terhadap : Diri saya sendiri/ Istri/ Suami/ Anak/ Ayah/ Ibu/ Saudara : *).......................................................... *)........................................................................ ..............  No Rekam Medis : Tanggal Lahir Agama Alamat Dirawat di Ruang

:........................................... :................................................................. ............................... ......... :.......................................................................... :.......................................................................... ............................................ .................................................................. ............................... ......... :................................Kamar:............. :................................Kamar:............................... ..................

Dengan ini saya meminta untuk dilayani oleh Rohaniawan berdasarkan agama dan kepercayaan saya .

Saksi

(...............................................)  Nama Petugas RS

Metro,........................................ Yang membuat pernyataan

(.............................................) Nama terang

RUMAH SAKIT MARDI WALUYO METRO Jl. Jendral Sudirman No 156 Metro Telp (0725) 42512 PENGKAJIAN SPIRITUAL PASIEN

 Nama :........................................ No MR : Tanggal Lahir:......................................... Ruang/ Kelas : 1. Pengkajian spiritual pasien dilakukan tanggal ..............................jam ................ 2. Keyakinan / Kepercayaan yang dianut pasien : □ Islam

□ Kristen

□ Khatolik

□ Hindu

□ Budha □ Lainnya

3. Nilai –  nilai hidup pasien : 

Makanan yang dipantang.........................................................................



 Nomor kamar/ Posisi kamar ...................................................................



Vegetarian



Lain –  lain :

□ Ya

□ Tidak

................................................................................................................... ................................................................................................................... 4. Evaluasi konseling ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................. ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... .............................................................................................................................. ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... .............................................................................................................................. Metro,.......................................... Pasien / Keluarga

(.........................................)  Nama Lengkap & tanda tangan

Yang Mengkaji

(..............................................) Nama Lengkap & tanda tang