DINAS KESEHATAN KABUPATEN WAKATOBI

UPTD PUSKESMAS WANGI-WANGI

Jl. Samburaka No. 1 Wangi-wangi 93791 Telp. (0404) 21118

RINGKASAN MASUK UNIT GAWAT DARURAT

NO. REKAM MEDIK

NO. REGISTER
Nama : Agama :
Tgl. Lahir : Jenis Kelamin :
Umur : Alamat :
Rujukan : Ya Rs dr Diantar Oleh :
Puskesmas Lainnya
Tidak Datang Sendiri
No. Kartu : No.Telp / HP :

Penyebab Cedera/Keracunan :
Kecelakaan Lalu Lintas (KLL) :
Kecelakaan Lainnya :
Tanggal Kejadian : Pukul : Tempat Kejadian :
ALERGI TERHADAP :
PEMERIKSAAN DOKTER : Tgl ………………………. Pukul ……………. s/d Pukul ………………..
JENIS KASUS :
ANAMNESE, PEMERIKSAAN FISIK, DIAGNOSA & THERAPY

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PEMERIKSAAN : KU : …................... Kesadaran/CGS : …………………………… Resusitasi : ……………
FISIK Tensi ……….….. Nadi ……………… Suhu …………….. Nafas ………………
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DIAGNOSA:
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THTERAPY:……………………………………………………………………………………………………...
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Tindak lanjut pelayanan : Dirawat Pulang Mati sebelum dirawat Dirujuk
Tanda tangan & nama terang Dokter Nama Dokter/Perawat yang melakukan tindakan
1. 5.
2. 6.
3. 7.

Ket : Beri Tanda √ pada □ yang perlu

 4.

Ket : Beri Tanda √ pada □ yang perlu