Form Hand Over Antar Shift / Serah Terima Antar Shift Jaga

FASHARKAN TNI AL MANOKWARI
RUMKITAL dr. AZHAR ZAHIR
FORMULIR SERAH TERIMA (HAND OVER) ANTAR SHIFT JAGA

RUANGAN :....................................................................... Nama Pasien : ...........................................................
HARI, TANGGAL :....................................................................... Tgl Lahir : ...........................................................
No. RM : ...........................................................
PAGI SORE MALAM

Situation :................................................................... Situation :................................................................... Situation :...................................................................
................................................................................... ................................................................................... ...................................................................................
................................................................................... ................................................................................... ...................................................................................
Background :............................................................. Background :............................................................. Background :.............................................................
.................................................................................. .................................................................................. ..................................................................................
Dx. Medis :................................................................ Dx. Medis :................................................................ Dx. Medis :................................................................
DPJP: dr.................................................................... DPJP: dr.................................................................... DPJP: dr....................................................................
Assesment :.............................................................. Assesment :.............................................................. Assesment :..............................................................
Kesadaran :.....................................GCS:................ Kesadaran :.....................................GCS:................ Kesadaran :.....................................GCS:................

TTV : TD:......................mmHg Nadi :..........x/menit TTV : TD:......................mmHg Nadi :..........x/menit TTV : TD:......................mmHg Nadi :..........x/menit
Suhu :............oC RR:...........x/menit Nyeri:................ Suhu :............oC RR:...........x/menit Nyeri:................ Suhu :............oC RR:...........x/menit Nyeri:................
Oksigen:.............L/menit Infus :..............tts/menit Oksigen:.............L/menit Infus :..............tts/menit Oksigen:.............L/menit Infus :..............tts/menit
Transfusi :..........tts/menit | Katheter:Y/T | NGT: Y/T Transfusi :..........tts/menit | Katheter:Y/T | NGT: Y/T Transfusi :..........tts/menit | Katheter:Y/T | NGT: Y/T
Makan/Minum :......................................................... Makan/Minum :......................................................... Makan/Minum :.........................................................
Toileting :.................................................................. Toileting :.................................................................. Toileting :..................................................................
Aktivitas/Gerak :....................................................... Aktivitas/Gerak :....................................................... Aktivitas/Gerak :.......................................................
Skore Jatuh :.......................................................... Skore Jatuh :.......................................................... Skore Jatuh :..........................................................
Recomendation :................................................... Recomendation :................................................... Recomendation :...................................................
............................................................................... ............................................................................... ...............................................................................
............................................................................... ............................................................................... ...............................................................................
Pemberi Operan Penerima Operan Pemberi Operan Penerima Operan Pemberi Operan Penerima Operan
(...............................) (...............................) (...............................) (...............................) (...............................) (...............................)

Form Hand Over Antar Shift / Serah Terima Antar Shift Jaga

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Form Hand Over Antar Shift / Serah Terima Antar Shift Jaga

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Format Tersedia

FASHARKAN TNI AL MANOKWARI

RUMKITAL dr. AZHAR ZAHIR

FORMULIR SERAH TERIMA (HAND OVER) ANTAR SHIFT JAGA

PAGI SORE MALAM

Assesment :.............................................................. Assesment :.............................................................. Assesment :..............................................................

Kesadaran :.....................................GCS:................ Kesadaran :.....................................GCS:................ Kesadaran :.....................................GCS:................

(...............................) (...............................) (...............................) (...............................) (...............................) (...............................)

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