Nama Pasien

Jenis Kelamin

FORMULIR TRANSFER PASIEN INTRA RSRP

: ...
No. Rekam Med
: ...

TGL lahir/Umur
DPJP
Dokter Konsulen 1
Dokter Konsulen 2
Diagnosa Masuk

: Tanggal Masuk
: Ruang/Kamar
:.....................................................Tanggal & 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.PEMERIKSAAN DIAGNOSTIK YANG SUDAH DILAKUKAN
Laboratorium:................................................................................................................................
.....................................................................................................................................................
EKG
Foto Abomen
CT Scan:...........
Toraks Foto
Spirometri
Endoscopi:........
Foto Cervical/Vetebra
Echo/ Treadmill
CTG
Foto Genu/Femur
USG/ MRI/A
Lain :..............................................................................................................................................
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II.TINDAKAN MEDIS YANG SUDAH DILAKUKAN
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III. PEMBERIAN THERAPI
Infus : ............................................................................................................................................
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Obat Injeksi:
1. ...............................................................
4. ......................................................................
2. ...............................................................
5. ......................................................................
3. .................................................................
6. ......................................................................
Obat Oral:
1. ...............................................................
5. ......................................................................
2. ...............................................................
6. ......................................................................
3. .................................................................
7. ......................................................................
4. ...............................................................
8. ......................................................................
Lain :..............................................................................................................................................
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(DPJP/Dokter IGD/Dokter Ruangan)

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Yang Mene
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RSRP
No. Rekam Medik
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Pernafasan:......x/mnt
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CT Scan:................................
Endoscopi:.............................

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Yang Menerima

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(DPJP/Dokter IGD/Dokter Ruangan)