DETASEMEN KESEHATAN WILAYAH 04.04.

04
RUMAH SAKIT TK. III SLAMET RIYADI

FORMULIR TRANSFER PASIEN

Nama Pasien : ...................................... Jenis Kelamin : ......................................

Tanggal Lahir : ...................................... Tanggal Masuk : ......................................
DPJP : ...................................... Ruang/Kamar : ......................................
Dokter Konsulen 1 : ...................................... Tanggal/ Jam Pindah : ......................................
Dokter Konsulen 2 : ...................................... Pindah ke Ruang/ Kamar : ......................................
Diagnosis Masuk : ...................................... Diagnosis Sekarang : ......................................

I. RINGKASAN RIWAYAT PASIEN

Anamnesis
Keluhan utama : .....................................................................................................
.....................................................................................................
Riwayat penyakit : .....................................................................................................
.....................................................................................................
Pemeriksaan Fisik
Pemeriksaan tanda-tanda vital : Tensi : mmHg, Suhu : 0C, Nadi : x/mnt
Keadaan Umum : .....................................................................................................
.....................................................................................................
Alasan Transfer : .....................................................................................................
.....................................................................................................

II. PEMERIKSAAN PENUNJANG YANG SUDAH DILAKUKAN

...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
TINDAKAN MEDIS YANG SUDAH DILAKUKAN
...........................................................................................................................................
...........................................................................................................................................

III. PEMBERIAN TERAPI

Infus : ........................................................................................................................
......................................................................................................................................
......................................................................................................................................
Obat Injeksi :
1. ........................................ 4. ........................................
2. ........................................ 5. ........................................
3. ........................................ 6. ........................................
Obat Oral :
1. ........................................ 5. ........................................
2. ........................................ 6. ........................................
3. ........................................ 7. ........................................
4. ........................................ 8. ........................................
Derajat kebutuhan perawatan pasien
Derajat 0 Derajat 2
Derajat 1 Derajat 3