SARI ASIH
FORMULIR TRANSFER PASIEN
Nama Pasien
: .........................................................................................
Jenis Kelamin
: L/P
Tanggal Lahir
: .........................................................................................
Tanggal Masuk
: .......................................................
DPJP
: .........................................................................................
Ruang / Kamar
: .......................................................
: .......................................................
Diagnosis Masuk
Diagnnosis Sekarang
: .........................................................................................
: .......................................................
Pemeriksaan Fisik
: ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
: ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
: ...............................................................................................................................................................................................................
0
Pemeriksaan tanda-tanda vital : Tensi :
mmHg
Suhu :
C
Nadi :
x/mnt
Keadaan umum
: ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
Alasan transfer
: ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
4. ...................................................................................................................
5. ...................................................................................................................
6. ...................................................................................................................
5.
6.
7.
8.
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
Derajat 2
Derajat 3
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
Petugas PK I
/ Petugas keamanan
Derajat 2
Dokter/Perawat PK II
Derajat 3
Dokter/Perawat PK III
V. KONDISI PASIEN
Sebelum Transfer
Setelah Transfer
Petugas Medis
Petugas Medis