FORM Transfer Pasien Intra RS [PDF]

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DETASEMEN KESEHATAN WILAYAH MALANG RUMAH SAKIT TINGKAT III BALADHIKA HUSADA FORM : 05



FORMULIR TRANSFER PASIEN INTRA RS Nama Pasien Jenis Kelamin Tgl lahir/umur DPJP



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Diagnosa Masuk



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No. RM Tanggal Masuk Ruang/Kamar Tgl & Jam Pindah Pindah ke Ruang / Kamar Diagnosa Sekarang



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I.



PEMERIKSAAN FISIK Keadaan Umum : .................................................................................................... Kesadaran : .................................................................................................... Pemeriksaan Tanda-tanda vital : Tensi : ..... mmHg, Suhu : ..... °C, Nadi : ..... x/mnt, Pernafasan : ..... x/mnt Keluhan : .................................................................................................... Riwayat Penyakit : .................................................................................................... Riwayat Alergi : .................................................................................................... Alasan Pindah Ruangan : .................................................................................................... II. MASALAH KEPERAWATAN : III. PEMERIKSAAN DIAGNOSTIK YANG SUDAH DILAKUKAN Laboratorium : .................................................................................................... EKG Foto Abomen CT Scan : ................................. Toraks Foto Spirometri Endoscopi : .............................. Foto Cervical / Vetebrata Echo/Treadmill CTG Foto Genu/Femur USG/MRI/A Lain : ...................................................................................................................................... IV. TINDAKAN MEDIS YANG SUDAH DILAKUKAN ..................................................................................................................................................... ..................................................................................................................................................... V. PEMBERIAN THERAPI Tgl / jam Pemberian Terapi : ...................................................................................................... Infus : ...................................................................................................................................... Obat Injeksi : 1. .................................................................. 2. .............................................................. 3. .............................................................. Obat Oral : 1. .............................................................. 2. .............................................................. 3. .............................................................. VI. Rencana Konsultasi Form Konsul : Terapi



: Terlampir



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Tidak



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Rencana pemeriksaan lab/radiologi ............................................................................................ Rencana tindakan lebih lanjut ...................................................................................................... Hasil Pemeriksaan :



Laboratorium Lain – lain



Radiologi



Dokumen yang disertakan : Surat masuk perawatan Berkas Rekam Medik Catatan Terintegrasi yang berisi instruksi / terapi Jaringan PA Laporan Operasi/Tindakan Mobilisasi : Kewaspadaan : Kebutuhan Khusus :



Gelang Nama Surat Rujukan Lain - lain



Mandiri Dibantu Standar Contact Protokol Risiko Pasien Jatuh Perawatan Luka Hygiene



Inform Consent



Dibantu Penuh Airbone Protokol Restrain



Droplet



Jam :



Jam :



Jam :



Disetujui Pasien / Penanggung Jawab



Perawat Yang Menyerahkan



Perawat Yang Menerima



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