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Nama : ...................................................................................

L/P
No. RM : ..........................................................................................
Tgl. Lahir / Umum : ...........................................................................................
CHECKLIST PASIEN KELUAR Ruang Rawat : ..........................................................................................
RUANG RAWAT INTENSIF Tanggal Masuk : ..........................................................................................

. Nama DPJP : ...................................................... Nama PPJP : ......................................................................................................

Diagnosa : ..........................................................................................................................................................................................

Kriteria Pasien Keluar :


1. Kesadaran
GCS : E ………………. M ………………. V ……………….
2. Tanda Vital
TD : …………………….. mmHg MAP : ………………. mmHg HR : ………………. x/menit reguler /irreguler
RR : …………………….. x/menit SatO2 : ……………………..%, dengan alat bantu nafas
Canal nasal : …………………….. lt/menit
NRM : …………………….. lt/menit
ETT : …………………….. lt/menit
Tracheostomi : …………………….. lt/menit
3. Nilai Laboratorium
Glukosa : …………………….. mg/dl PH darah : …………………….. Natrium : …………………….. mEq/L
Ureum : …………………….. mg/dl Pa O2 : …………………….. mmHg Kalium : …………………….. mEq/L
Kreatinin : …………………….. mg/dl PC O2 : …………………….. mmHg
Lain-lain : ……………………..
4. Radiologi :

5. Elektrokardiogram : Normal / Abnormal ..........................................................................................................................................

6. Kondisi lain :

Menolak intervensi aktif ( menandatangani form penolakan tindakan )


Pasien dalam keadaan vegetative permanen
Pasien / keluarga menolak di rawat intensif
Lainnya :
.....................................................................................................................................................................................................

7. Masalah yang harus diperhatikan :

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

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

Kesimpulan :

Pasien datang dapat dipindahkan dari ruang rawat intensif : ICU, ICCU, PICU, HCU, PERISAKIT *)
Dipindah ke ruang : .........................................................................................................................................................................................

Bekasi, Tgl. ......................................... Jam .................... Bekasi, Tgl. ............................... Jam .......................
DPJP ruang rawat intensif Dokter jaga intensif

(Tanda tangan & Nama Jelas) (Tanda tangan & Nama Jelas)

*) Coret yang tidak perlu