Nomor MR :

Nama Lengkap :
Tanggal Lahir :
Jenis Kelamin :

CATATAN MEDIS
GAWAT DARURAT

(Tempelkan stiker pasien jika tersedia)

1. Formulir ini khusus untuk Dokter di Unit Gawat Darurat RSU Hasanah Graha Afiah
2. Beri tanda (a) pada kotak yang tersedia sesuai dengan hasil pemeriksaan
Tanggal/ Jam Datang
1.

Triage
Prioritas Triage

Cara Pasien Datang

2.

RM01.99/00/2015

Merah

Kuning

Trauma

Non Trauma

Sendiri

Diantar :

Ambulans

Hijau

Hitam

DOA

Pemeriksaan Dokter
A. Data Subyektif

Auto Anamnesa

Riwayat Alergi

Tidak Ada

Ada

Allo Anamnesa

Riwayat Penyakit Terdahulu :

B. Data Obyektif

Keadaan umum

Baik

Sedang

Buruk

Kesadaran

CM

Apatis

coma

Soporocoma

Coma

GCS

E M V

Status Psikologis

Marah

Cemas

Total :
Gelisah

Tidak Ada Masalah

Takut

Depresi

Kecenderungan

Lain-lain

Bunuh Diri
Nilai Nyeri *)

(Tidak ada nyeri - Nyeri sangat berat)

Lokasi :
Durasi :

*)Lingkari angka yang sesuai dengan keluhan pasien

3.

4.

Tanda Vital
Tekanan Darah

mmHg

Suhu

oC

Pernafasan
Nadi

:
:

x/mnt
x/mnt

Saturasi O2

:
:

%
Kg

Berat Badan

Gambar Tubuh

Pemeriksaan Fisik
Normal

Jika Tidak Normal, Jelaskan

Kepala

Mata

Mulut

Leher

Dada

Perut

c Luka/Lesi

Alat Gerak

c Perdarahan

Anus-Genitalia

5.

Pemeriksaan Penunjang

Laboratorium
: ........................................................................................................................
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Radiologi

.......................................................................................................................

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..
..

..

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..

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..

Lainnya

Diagnosa Kerja

EKG

............................................................................................

..

CTG

............................................................................................

.......................................................................................................................

Diagnosa Banding
:

Tindakan - Pengobatan

Saat di UGD
................................................................................................................................................................

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Tindak Lanjut

Nama Dokter :

Pulang

Rawat

Rujuk

Meninggal

Pulang Paksa

Tanda Tangan :

Terapi Rawat Inap

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Lembar Observasi
TGL/Jam

Kesadaran (GCS)

TD

Nadi

RR

Nama Dokter :

bar Observasi
Suhu

Sat. O2

Keterangan

Nama Dokter

Tanda Tangan :

CATATAN MEDIS
GAWAT DARURAT
1. Formulir ini khusus untuk Dokter di Unit Gawat Darurat RSU Hasanah Graha Afiah
2. Beri tanda (a) pada kotak yang tersedia sesuai dengan hasil pemeriksaan
Tanggal/ J
1.

Triage
Prioritas Tr

Cara Pasie

2.

Merah

Kuning

Trauma

Non Trauma

Sendiri

Diantar :

Ambulans

Pemeriksaan Dokter
A. Data Sub

Auto Anamnesa

Riwayat Ale

Tidak Ada c

Riwayat Penyakit Terdahulu :

B. Data Oby

Ada

Keadaa

Baik

Sedang

Kesadar

CM

Apatis

Soporocoma

GCS

E M V

Status P

Marah

Cemas

Takut

Depresi

Nilai Nyeri

(Tidak ada nyeri - Nyeri sangat berat)

*)Lingkari angka yang sesuai dengan keluhan pasien

3.

Tanda Vital
Tekanan Da

mmHg

Pernafasan
Nadi

:
:

x/mnt
x/mnt

Nomor MR :
Nama Lengkap :
Tanggal Lahir :
Jenis Kelamin :

(Tempelkan stiker pasien jika tersedia)

ah Graha Afiah
RM01.99/00/2015

Hijau

Hitam

on Trauma

iantar : c

Allo Anamnesa

da

DOA

Buruk

Somnolen

Coma
Total :

Gelisah

Kecenderu c

Tidak Ada Masalah

Lain-lain

Bunuh Diri

Lokasi :
Durasi :

Suhu

oC

Saturasi O2

:
:

%
Kg

Berat Badan