Formulir Transfer Pasien [PDF]

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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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