FORMULIR NOMOR RM :

TRANSFER INTERNAL Nama Lengkap :

Tgl Lahir umur : L/P*)
Tanggal & jam transfer : ....................................................................................................................................
Tanggal & jam transfer : ....................................................................................................................................

Tujuan Transfer : Ruangan................ Pemeriksaan Tindakan ................

Kami kirimkan Pasien penunjang atau Operasi
Asal Ruangan / Klinik : ...................................................................
Diagnosa Utama : ............................................................................. Peralatan yang terpasang :
Diagjosa Sekunder : ............................................................................. Airway:
Skala Nyeri (1-10) : ................................................................... . Tanpa alat bantu
Kesadaran : GCS :........... E : ......... V :......... M : .................... OPA / NPA
Tekanan Darah :............... mmhg Nadi : ....... Pernafasan : .......... Laringeal Mask Airway
O Endotracheal tube
Suhu : ...... C Nadi : ......Pernafasan :....
Diet : ................................................................... Tracheostomy
Per Oral :................kkal, frekuensi...........kali/24 jam
Breathing
Per NGT/OGT : ...............................................................................................................
Ventilasi :
Per Tube : .............................................................................
Nafas Spontan
Infus : Jenis cairan ........................................... cc/24jam Napas dibantu
Transfusi : Whole Blood .......................... cc Oksigenisasi
Packged Red Cell ................... cc Kanul
Fresh frozen Plasma.............. cc Simple mask
Trombosit.............................. cc Non rebreathing mask
Jackson rees
Pemeriksaan penunjangan ....
Rontgen thorax CT Scan Lain-lain :
Folley kateter
USG EKG
Thorakotomi Tube
Laboratorium Urine Lengkap
NGT/OGT
...
Terapi Terakhir : ..................................................................................................... ...
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................................................................................................................................ Kondisi Pasien berdasarkan
................................................................................................................................ Nilai skoring Peringatan Dini
................................................................................................................................ Ringan/Hijau :.
Rekomendasi : ....................................................................................................... Sedang/Kuning :
................................................................................................................................ Berat/pink :..
Sangat berat/merah
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Tindak Lanjut Perawatan : ....................................................................................................................................
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