Nomor MR :

CATATAN MEDIS Nama Lengkap :

Tanggal Lahir :
GAWAT DARURAT Jenis Kelamin :
(Tempelkan stiker pasien jika tersedia)

1. Formulir ini khusus untuk Dokter di Unit Gawat Darurat RSU Hasanah Graha Afiah
2. Beri tanda (a) pada kotak yang tersedia sesuai dengan hasil pemeriksaan RM01.99/00/2015

Tanggal/ Jam Datang :

1. Triage

Prioritas Triage : c Merah c Kuning c Hijau c Hitam

c Trauma c Non Trauma
Cara Pasien Datang : c Sendiri c Diantar : ……………………………………… c DOA
c Ambulans

2. Pemeriksaan Dokter

A. Data Subyektif : c Auto Anamnesa c Allo Anamnesa

Riwayat Alergi : c Tidak Ada c Ada …………………………………

Riwayat Penyakit Terdahulu :

B. Data Obyektif :

Keadaan umum : c Baik c Sedang c Buruk

Kesadaran : c CM c Apatis c Soporocoma

c Coma

GCS : E …………… M …………… V …………… Total : ……………

Status Psikologis : c Marah c Cemas c Gelisah c Tidak Ada Masalah

c Takut c Depresi c Kecenderungan c Lain-lain
Bunuh Diri

Nilai Nyeri *) : (Tidak ada nyeri - Nyeri sangat berat)

Lokasi : ………………………
Durasi : ………………………

*)Lingkari angka yang sesuai dengan keluhan pasien

3. Tanda Vital
Tekanan Darah : …………………… mmHg Suhu : …………………… oC
Pernafasan : …………………… x/mnt Tinggi Badan : …………………… cm
Nadi : …………………… x/mnt Berat Badan : …………………… Kg

4. Pemeriksaan Fisik Gambar Tubuh

Normal Jika Tidak Normal, Jelaskan

Kepala c

Mata c
Mulut c

Leher c

Dada c

Perut c c Luka/Lesi
Alat Gerak c c Perdarahan
Anus-Genitalia c
 5. Pemeriksaan Penunjang

c Laboratorium : ........................................................................................................................ …..

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c Radiologi : ....................................................................................................................... ………………..

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c Lainnya : c EKG ............................................................................................ ………………..

c CTG ............................................................................................ …………………

Diagnosa Kerja : ....................................................................................................................... …………………

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Diagnosa Banding :

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Tindakan - Pengobatan :

Saat di UGD

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Tindak Lanjut : c Pulang c Rawat c Pulang Paksa

c Rujuk c Meninggal

Nama Dokter : Tanda Tangan :

Terapi Rawat Inap

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 Lembar Observasi

TGL/Jam Kesadaran (GCS) TD Nadi RR Suhu Sat. O2

Nama Dokter : Tanda Tangan :
Keterangan Nama Dokter
 Nomor MR :
CATATAN MEDIS Nama Lengkap :
Tanggal Lahir :
GAWAT DARURAT Jenis Kelamin :
(Tempelkan stiker pasien jika tersed

1. Formulir ini khusus untuk Dokter di Unit Gawat Darurat RSU Hasanah Graha Afiah
2. Beri tanda (a) pada kotak yang tersedia sesuai dengan hasil pemeriksaan

Tanggal/ :
1. Triage

Prioritas : c Merah c Kuning c Hijau

c Trauma c Non Trauma
Cara Pasi : c Sendiri c Diantar : ……………………………
c Ambulans

2. Pemeriksaan Dokter

A. Data Su : c Auto Anamnesa c Allo Anamnesa

Riwayat Al : c Tidak Ada c Ada …………………………………

Riwayat Penyakit Terdahulu :

B. Data Ob :
 Keada : c Baik c Sedang c Buruk

Kesada : c CM c Apatis c Somnolen

c Soporocoma c Coma

GCS : E …………… M …………… V …………… Total : ……………

Status : c Marah c Cemas c Gelisah

c Takut c Depresi c Kecender
Bunuh Diri

Nilai Nye : (Tidak ada nyeri - Nyeri sangat berat)

*)Lingkari angka yang sesuai dengan keluhan pasien

3. Tanda Vital
Tekanan D : …………………… mmHg Suhu
Pernafasa : …………………… x/mnt Saturasi O2
Nadi : …………………… x/mnt Berat Badan
or MR :
Lengkap :
gal Lahir :
Kelamin :
elkan stiker pasien jika tersedia)

RM01.99/00/2015

c Hitam

c DOA

Allo Anamnesa
Somnolen

Total : ……………

c Tidak Ada Masalah

c Lain-lain
Bunuh Diri

Lokasi : ………………………
Durasi : ………………………

: …………………… oC
: …………………… %
: …………………… Kg