Form Isian Sisrute [PDF]

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FORM DATA PASIEN YANG DIRUJUK DALAM APLIKASI SISRUTE NO. REKAM MEDIS NAMA PASIEN NO. KONTAK ALAMAT LENGKAP



TEMPAT LAHIR: TANGGAL LAHIR JENIS KELAMIN NO KARTU JKN NIK (KTP) TUJUAN RUJUK TRANSPORTASI PILIH AMBULANCE JENIS RUJUKAN ALASAN RUJUKAN



: .......................................................................................................................... : .......................................................................................................................... : ................................. (KELUARGA PENDAMPING ......................................) ................................. (PERAWAT PERUJUK ...............................................) : .......................................................................................................................... .......................................................................................................................... ..........................................................................................................................



: (0000-00-00 / TAHUN-BULAN-HARI) : LAKI/PEREMPUAN : .......................................................................................................................... : .......................................................................................................................... : RS .................................................................................................................... : AMBULANCE/PESAWAT/KENDARAAN AIR : NO PLAT ................................. DRIVER ......................................................... : RAWAT JALAN/RAWAT DARURAT : - PENANGANAN/PERAWATAN LANJUT PASIEN (MEDIK) - SARANA PRASARANA (RUANG PERAWATAN BIASA) - SARANA PRASARANA (RUANG INTENSIVE : ICU, NICU, PICU, HCU) - SARANA PRASARANA (RUANG ISOLASI) - DOKTER SPESIALIS/SUB SPESIALIS TIDAK TERSEDIA - TINDAKAN KHUSUS KETERANGAN : .......................................................................................................................... .......................................................................................................................... DIAGNOSA : .......................................................................................................................... .......................................................................................................................... KU PASIEN : SADAR/TIDAK SADAR TTV : TD ................. MMHG NADI .......... X/MENIT RR .......... X/MENIT SUHU ............ °C NYERI : BERAT/RINGAN/TIDAK NYERI KETERANGAN LAIN (KELUHAN/PEMERIKSAAN FISIK) : .......................................................................................................................... .......................................................................................................................... HASIL LAB : .......................................................................................................................... .......................................................................................................................... HASIL RADIOLOGI (RO, USG, EKG) : .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... TERAPI/TINDAKAN YANG DIBERIKAN (INFUS, INJEKSI, ORAL, TERPASANG ALAT INVASIF) : .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... ..........................................................................................................................