Form Hand Over Antar Shift [PDF]

FASHARKAN TNI AL MANOKWARI RUMKITAL dr. AZHAR ZAHIR

FORMULIR SERAH TERIMA (HAND OVER) ANTAR SHIFT JAGA RUANGAN

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FASHARKAN TNI AL MANOKWARI RUMKITAL dr. AZHAR ZAHIR

FORMULIR SERAH TERIMA (HAND OVER) ANTAR SHIFT JAGA RUANGAN

:.......................................................................

Nama Pasien : ...........................................................

HARI, TANGGAL

:.......................................................................

Tgl Lahir

: ...........................................................

No. RM

: ...........................................................

PAGI

SORE

MALAM

Situation :................................................................... ................................................................................... ...................................................................................

Situation :................................................................... ................................................................................... ...................................................................................

Situation :................................................................... ................................................................................... ...................................................................................

Background :............................................................. ..................................................................................

Background :............................................................. ..................................................................................

Background :............................................................. ..................................................................................

Dx. Medis :................................................................

Dx. Medis :................................................................

Dx. Medis :................................................................

DPJP: dr....................................................................

DPJP: dr....................................................................

DPJP: dr....................................................................

Assesment :..............................................................

Assesment :..............................................................

Assesment :..............................................................

Kesadaran :.....................................GCS:................

Kesadaran :.....................................GCS:................

Kesadaran :.....................................GCS:................

TTV : TD:......................mmHg Nadi :..........x/menit

TTV : TD:......................mmHg Nadi :..........x/menit

TTV : TD:......................mmHg Nadi :..........x/menit

Suhu :............oC RR:...........x/menit Nyeri:................

Suhu :............oC RR:...........x/menit Nyeri:................

Suhu :............oC RR:...........x/menit Nyeri:................

Oksigen:.............L/menit

Oksigen:.............L/menit

Oksigen:.............L/menit

Infus :..............tts/menit

Infus :..............tts/menit

Infus :..............tts/menit

Transfusi :..........tts/menit | Katheter:Y/T | NGT: Y/T

Transfusi :..........tts/menit | Katheter:Y/T | NGT: Y/T

Transfusi :..........tts/menit | Katheter:Y/T | NGT: Y/T

Makan/Minum :.........................................................

Makan/Minum :.........................................................

Makan/Minum :.........................................................

Toileting :..................................................................

Toileting :..................................................................

Toileting :..................................................................

Aktivitas/Gerak :.......................................................

Aktivitas/Gerak :.......................................................

Aktivitas/Gerak :.......................................................

Skore Jatuh :.......................................................... Recomendation :................................................... ............................................................................... ............................................................................... Pemberi Operan Penerima Operan

Skore Jatuh :.......................................................... Recomendation :................................................... ............................................................................... ............................................................................... Pemberi Operan Penerima Operan

Skore Jatuh :.......................................................... Recomendation :................................................... ............................................................................... ............................................................................... Pemberi Operan Penerima Operan

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