RUMAH SAKIT HARAPAN BUNDA NRM :

Jl. T.Umar No.181 - 211 Banda Aceh Nama :

Telp (0651) 48114 Fax. (0651) 40856 Tgl.Lahir :
Jenis Kelamin :

FORM TRANSFER PASIEN INTRA RSHB

NAMA PASIEN : .............................................. Nama DPJP : .................................................
TANGGAL MASUK : ............................................... ASAL RUANGAN : .................................................
JAMINAN : ............................................... RUANGAN DITUJU : .................................................
DIAGNOSIS MASUK : ............................................... JAM PINDAH : .................................................

1. PEMERIKSAAN FISIK
A. Keadaan Umum : .................................................................................................................................
B. Kesadaran : E: M: V:
C. Tanda – tanda Vital
D. Keluhan Masuk : .................................................................................................................................
E. Riwayat Penyakit : .................................................................................................................................
F. Riwayat Alergi : ............................................................................ Terpasang Gelang : Ya / Tidak
2. PEMERIKSAAN PENUNJANG YANG DILAKUKAN
A. Laboratorium : .................................................................................................................................
B. ECG : Sudah / Belum
C. Radiologi : .................................................................................................................................
D. CT Scan : .................................................................................................................................
E. Lain – lain : .................................................................................................................................
3. PEMBERIAN TERAPI
A. INFUS : .................................................................................................................................
B. OBAT INJEKSI
a. ................................................................... c. ..........................................................................
b. ................................................................... d. ..........................................................................
C. OBAT ORAL
a. ................................................................... c. ..........................................................................
b. ................................................................... d. ..........................................................................
4. KONDISI PASIEN
A. Kondisi Pasien Saat Dipindahkan : Sadar/Tidak Sadar, Stabil/Tidak Stabil
B. Resiko Jatuh : Ya / Tidak Terpasang Gelang : Ya / Tidak
C. Cara Pemindahan Pasien : Jalan Brankar Kursi Roda Lain-lain
D. Waktu Serah Terima Pasien : Banda Aceh, Tanggal ..........................., Jam : ..................WIB
E. Catatan Penting : .........................................................................................................
5. KONDISI AKHIR PASIEN
a. Keadaan Umum : d. Frekuensi Nadi :
b. Kesadaran : e. Frekuensi Nafas :
c. Tekanan Darah : f. Suhu :

Yang Menerima Pasien Yang Menyerahkan Pasien

Petugas Medis Petugas Medis

(Sdr/i ......................................) (Sdr/i ......................................)

Nama Jelas dan tandatangan Nama Jelas dan tandatangan

Mohon mengisi formulir ini dengan benar, lengkap dan Tulisan Jelas 019/RMHB/2016