03
Nama Pasien
: ......................................
No. RM
Jenis Kelamin: L / P
Tgl Lahir :
............................./.........Thn/ Bln/ Hr
Ruang/ Kelas
: ......................................
: ............... ............................................................................................................
Tingkat Kegawatan
Jenis Pelayanan
Alasan Datang
Cara Masuk
Merah
Bedah
Penyakit
Sendiri
Kuning
Hijau
Hitam
Non Bedah Kebidanan Anak
Trauma / Ruda paksa
Rujukan ...........................................
Jam : .................
Nadi
: .......... x/mnt
Pernafasan : .......x/mnt
SPO3
: ............................. %
CPR
Suction
Haecting
O2
Infus
Trakeostomi BVM
Obat .........................................
NGT
Bidai
Lain
Anemnesa Perawat
Jam : .......................
Keluhan Utama
: .....................................................................................................................................................
Anamnesa
: .....................................................................................................................................................
.....................................................................................................................................................
: .....................................................................................................................................................
Riwayat Alergi
B. Breathing
Pola Nafas : Teratur
Tidak Teratur
Bronchovesikuler
Whezing
Ronchi
Pola Nafas
Dyspneu
Bradipneu
Takhipneu
: Apneu
Orthopneu
Cuping hidung
Pernafasan perut
C. Circulation
Akral
: Hangat
Dingin
Pucat
: Ya
Tidak
Cianosis : Ya
Tidak
Tekanan Darah
: ............./ .................mmHg
> 2 detik
Tidak teraba
Tidak
Muntah
Luka bakar
Perdarahan
: Normal
Kurang
Diagnosa Keperawatan :
RM.03.a
D. Disability
Tingkat Kesadaran : Compos metis
Apatis
M ................... V...........................
Anak
Pupil
:A V
: Miosis
Respon Cahaya :
Somnolen
Sopor
Coma
Midriasis
+ / -
Tidak
Motorik : Ya Tidak
Diagnosa Keperawatan : Gangguan perfusi jaringan cerebral
Resiko Jatuh
Intoleransi Aktifitas
Kejang Ulang
Komunikasi Verbal
Penurunan Kesadaran
: Tidak Beresiko
Resiko Rendah
Resiko Tinggi
E. Exposure
Pengkajian Nyeri :
Apakah ada nyeri : Ya, skor nyeri ................... Tidak
Penjajaran Nyeri
Tipe
: Akut
Lokasi Nyeri
Kronik
: Jarang
Hilang Timbul
Terus Menerus
Lama Nyeri
: .................................................................................
Onset
: .................................................................................
: .................................................................................
Hipotermi
Laborat
: Ada.......................................................... Tidak
GDA
: Ada........................................................... Tidak
Radiologi
: Ada.......................................................... Tidak
Perawat
( ........................................................)
Nama Terang dan Tanda Tangan
RM.03.b
Pemeriksaan Fisik (Diisi Oleh Dokter)
Anamnesa Dokter : ............................................................................................................................................Jam :
...................................................................................................................................................
Organ
Norma
Temuan
Kepala
Leher
Thorax
Abdomen
Genetalia
Anus
Ekstermitas atas & bawah
Pemeriksaan Penunjang
: EKG
Radiologi :
Thorax
CT Scan
Lain .............................................
Laboratorium .....................................................................................................................
Diagnosis Kerja
: .................................................................................................................................................
.................................................................................................................................................
Diagnosis Banding
Tgl & Jam
: .................................................................................................................................................
Terapi Dokter
S
O
A
P
S
O
A
P
Dokter
( ........................................................)
Nama Terang dan Tanda Tangan
RM.03.c
Tindakan Keperawatan
Tgl dan Jam
Tindakan Keperawatan
Dosis
Cara
Paraf
dokte
r
UGD
Siang
Malam
Observasi Lanjutan
Tgl dan Jam
GCS
RR
Sat
Keluhan
TTD
Lokasi
Keterangan
Jenis
IV Line
Kateter
CVC
NGT
Lain- lain
ETT
Ukuran
Keterangan
Hasil Akhir
Keluar IGD : tanggal : ............................................. Jam : ............................ dengan tindak lanjut pelayanan :
Dirawat di ruangan ............................................ Kelas..............., Discharge planning .......................................hari.
Kamar operasi ................................................... Tanggal : ............................................ Jam : .........................WIB.
Rujuk ke ........................................................... Alasan rujuk : Indikasi medis Tempat Penuh Permintaan pasien
Pulang : Indikasi medis
Jam :
TTD Dokter IGD
( ......................................................)
( ......................................................)
( ......................................................)
RM.03.d
Diisi Bila Dilakukan Resusitasi Jantung Paru pada Pasien
Diagnosa dan Rencana Tindakan Keperawatan
Diagnosis/ indikasi dilakukan resusitasi jantung paru :
Dimulai pada pukul : ..............................................................................................................................................................
Diakhiri pada pukul : ..................................................... Lama resusitasi jantung paru : .......................................................
Resusitasi jantung paru dilakukan oleh : Dokter : ...............................................................................................................
Perawat ...............................................................................................................
Dilakukan intubasi pada jam : ....................................... Ukuran ETT : ......................................... Batas : ............................
Pelaksanaan intubasi : Dokter Perawat
Observasi
Nadi
RR
Tekanan Darah
Keterangan
Terapi
Ganbaran EKG
SPO2
Nama Obat
Dosis
Rute
DEFIBRILASI
Waktu
Ritme EKG
Joules
Ritme EKG
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Ruang umum
Meninggal
Natar, ........................................... Jam :
Dokter
Nama Perawat
( .....................................................)
( .....................................................)