RSUD MUNTILAN KABUPATEN MAGELANG

No RM :

FORMULIR Nama : L/P

SERAH TERIMA PASIEN
Tgl. Lahir :

Diagnosa : .............................................
DPJP : .............................................
DPJP II : .............................................

I. TINDAKAN PERAWATAN DI RUANGAN

1. Pasang infus 6. ..........................................................
2. Pasang DC 7. ..........................................................
3. Pasang NGT 8. Pasang O2 ......................................
4. Pasang Gips 9. ..........................................................
5. Pasang spalk 10. ..........................................................

II. PERLENGKAPAN OBAT YANG DIBAWA

Cairan : Obat-obatan :
1. RD 5% 1. ..........................................................
2. RL 2. ..........................................................
3. NaCl 0,9% 3. ..........................................................
4. Dex 5% 4. ..........................................................
5. Pan Amin G 5. ..........................................................
6. Manitol 6. ..........................................................
7. 2A
8. Aminofusin 600
9. Darah
10. .....................................

III. OBAT YANG TELAH DIBERIKAN

- ...........................................................................
- ...........................................................................
- ...........................................................................

IV. KONDISI PASIEN SEKARANG

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

Muntilan, .....................................

Petugas Ruang ............................ Petugas Ruang ...........................

Yang menyerahkan Yang menerima

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

Keterangan :
(√) : Ada / telah dilaksanakan
(-) : tidak ada / belum dilaksanakan
Isi dengan lengkap, jelas dan terbaca RM20