OBSRVATION FORM

KOMPETENSI 1 : Menerapkan Konsep, prinsip Etika Keperawatan dan Komunikasi

dalam Praktik Keperawatan Profesional
SUB KOMPETENSI : Berkomunikasi dalam bahasa inggris
JUDUL UNIT : Melakukan percakapan dalam bahasa Inggris

NO ELEMEN KRITERIA PENCAPAIAN KOMPETEN KOMENTAR

KOMPETENSI YA TIDAK
1 Establishing a 1.Greeting
relationship 2.Introducing
3.Explain the responsibility of nurse
4.Addressing some one
5.Pre closing
6.Closing
7.Polite request
2 Addmission to 8. Asking name
A Hospital 9.Asking date of birth
10.Asking age
11.Asking address
12.Asking ocupation
13.Asking civil state
14.Asking Religion
15.Asking Education
16. Phone Number
17. Next of kin
3 Asking Health 19. Check the patient complain
Problem 20.check history of health
21.check act/intervention
22.check location of the problem
4 Checking vital 23. check respiration
sign
24. check blood pressure
25. measure body temperatur
26.check pulse
5 Expression / 27. stance & posture
Body Language 28. Smile in the right time
29.Eye contact
28.Movement
30.Facial expression
6 Documentation 31.

Institution :

Name of Presentator:1................................... Yogyakarta, ...........................................

2................................. Observer,

Mark: _____ =................

31 ..................................................