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RUMAH SAKIT
SARI ASIH FORMULIR TRANSFER PASIEN Nama Pasien
: .........................................................................................
Jenis Kelamin
: L/P
Tanggal Lahir
: .........................................................................................
Tanggal Masuk
: .......................................................
DPJP
: .........................................................................................
Ruang / Kamar
: .......................................................
Dokter Konsulen 1 : .........................................................................................
Tanggal / Jam Pindah
: .......................................................
Dokter Konsulen 2 : .........................................................................................
Pindah ke Ruang / Kamar : .......................................................
Diagnosis Masuk
Diagnnosis Sekarang
: .........................................................................................
: .......................................................
I. RINGKASAN RIWAYAT PASIEN Anamnesis Keluhan utama Riwayat penyakit
Pemeriksaan Fisik
: ............................................................................................................................................................................................................... ............................................................................................................................................................................................................... : ............................................................................................................................................................................................................... ............................................................................................................................................................................................................... ............................................................................................................................................................................................................... : ...............................................................................................................................................................................................................
0 Pemeriksaan tanda-tanda vital : Tensi : mmHg Suhu : C Nadi : x/mnt Keadaan umum : ............................................................................................................................................................................................................... ............................................................................................................................................................................................................... ...............................................................................................................................................................................................................
Alasan transfer
: ............................................................................................................................................................................................................... ...............................................................................................................................................................................................................
II. PEMERIKSAAN PENUNJANG YANG SUDAH DILAKUKAN ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. III. TINDAKAN MEDIS YANG SUDAH DILAKUKAN ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. IV. PEMBERIAN TERAPI Infus : .............................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. Obat Injeksi : 1. ................................................................................................................... 2. ................................................................................................................... 3. ................................................................................................................... Obat Oral : 1. ................................................................................................................... 2. ................................................................................................................... 3. ................................................................................................................... 4. ................................................................................................................... Derajat kebutuhan perawatan pasien Derajat 0 Derajat 1
4. ................................................................................................................... 5. ................................................................................................................... 6. ................................................................................................................... 5. 6. 7. 8.
................................................................................................................... ................................................................................................................... ................................................................................................................... ................................................................................................................... Derajat 2 Derajat 3
KATEGORI PASIEN TRANSFER Level Kategori Derajat 0 Pasien membutuhkan ruang perawatan biasa.
Pendamping TPK / Petugas keamanan
Peralatan Semua rekam medik, hasil pemeriksaan penunjang, format transfer internal Peralatan derajat 0+ tabung oksigen dan canul, stand infus dan pulse oksimetri.
Derajat 1
Pasien beresiko mengalami perburukan, pasien baru pindah dari HCU/ICU, pasien yang akan dirawat diruang perawatan tim perawatan khusus.
Petugas PK I / Petugas keamanan
Derajat 2
Pasien memerlukan pengawasan ketat atau intervensi khusus, mis : pada pasien yang mengalami kegagalan satu sistem organ.
Dokter/Perawat PK II
Peralatan derajat 1, + bedside monitor, syringe pump.
Derajat 3
Pasien mengalami kegagalan multi organ dan memerlukan bantuan hidup jangka panjang ditambah dengan kebutuhan akan alat bantu nafas.
Dokter/Perawat PK III
Peralatan derajat 2, + alat bantu nafas.
V. KONDISI PASIEN Sebelum Transfer
Setelah Transfer
Keadaan umum : ...................................................................................... Kesadaran : ...................................................................................... Pemeriksaan tanda-tanda vital : mmHg Tensi : 0 C Suhu : x/mnt Nadi :
Keadaan umum : ...................................................................................... Kesadaran : ...................................................................................... Pemeriksaan tanda-tanda vital : mmHg Tensi : 0 C Suhu : x/mnt Nadi :
Catatan penting : ...................................................................................... ...................................................................................... ...................................................................................... ......................................................................................
Catatan penting : ...................................................................................... ...................................................................................... ...................................................................................... ......................................................................................
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