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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

: ...............................................................................................................................................................................................................
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: ...............................................................................................................................................................................................................
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: ...............................................................................................................................................................................................................

0
Pemeriksaan tanda-tanda vital : Tensi :
mmHg
Suhu :
C
Nadi :
x/mnt
Keadaan umum
: ...............................................................................................................................................................................................................
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Alasan transfer

: ...............................................................................................................................................................................................................
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II. PEMERIKSAAN PENUNJANG YANG SUDAH DILAKUKAN


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III. TINDAKAN MEDIS YANG SUDAH DILAKUKAN
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IV. PEMBERIAN TERAPI
Infus : ..............................................................................................................................................................................................................................................
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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.

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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 : ......................................................................................


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Catatan penting : ......................................................................................


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Petugas yang menyerahkan

Petugas yang menerima

Petugas Medis

Petugas Medis