Nama Pasien : ...................................... No.

RM :

Jenis Kelamin: L / P Tgl Lahir : ............................/......... Thn / Bln / Hr

Ruang / Kelas: .........................../........... Tgl Masuk : ................................... Jam : ..............

CATATAN AMBULAN DAN EVAKUASI

A. Permintaan Ambulan Internal
Diagnosa rujukan : ............................................................................... Alasan rujuk / pindah : ................................................................ Dokumen
Tanggal / jam permintaan : ............................................/.......................... WIB Tanggal / yang disiapkan : ................................................................
jam berangkat : ............................................/.......................... WIB Dokter penanggung Resume Medis/ Rujuk Hasil Lab dan Radiologi
jawab : ............................................................................. Asal Nama petugas RS tujuan yang menyetujui : ..........................................
ruangan : ...........................................................................

B. Permintaan Ambulan External

No. telp yang menghubungi : ........................................................................... Alasan Tanggal / jam berangkat : ..................................../ ................... WIB Tanggal /
penjemputan : ........................................................................... Tanggal / jam jam tiba di RS : ..................................../ ................... WIB
permintaan : ............................................./ ..................... WIB Sarana Evakuasi Cek kebenaran telp dengan menghubungi kembali
Ambulan Non Ambulan ............................................. Cek ketersediaan ruangan sesuai indikasi pasien

Petugas Evakuasi
1. .................................................. 3. ....................................................
2. .................................................. 4. .................................................... Alasan Trasnportasi
Rujuk ke RS ........................... Pindah ke RS ........................... APS Dipulangkan Lainnya, ……................ Keluhan
Utama : ........................................................................................................................... ..............................................................................................
............................................................................................................................. ...........................................................................................................................
TRIAGE
Merah Kuning Hijau Hitam
Jenis Transportasi
Emergency Non Emergency
SURVEI PRIMER Jam : ....................
Airway Breathing Exposure
Patent Spontan Luka terbuka
Obstruksi Total Tachypnoe Benda asing yang menancap
Obstruksi Pasrsial Kusmaul Hipotermia Bradypnoe Heat stroke Apnoe
DAFTAR MASALAH / KONDISI KHUSUS : ........................................................................................................................... ................................................
............................................................................................................................................................................ .............................................................................
.................................................................................................................................................................................. .......................................................................
INTERVENSI Jam : .............

Airway Breathing Circulation Exsposure Peralatan

Oropharyngeal Tube Endo Nasal Canule ..................Lpm Simpel Mask

IVFD...................Lpm
( Jenis Cairan )Non Rebreathing Bebat
Mask....Lpm
tekan Rebreathing ....................Lpm
Monitor InfusVenturi
Pump Mask
Syringe
........
Pu
Tracheal Tube Nasopharingeal 1. ...................Tpm/..........cc Bidai
Tube Lain-lain................ 2. ...................Tpm/..........cc Immobilasi Penuh Cegah
.................................... 3. ...................Tpm/..........cc hipotermia Cervical collar
Folley Catheter No..... NGT Lain-lain........
No...............

CATATAN OBSERVASI

Jam BP (mmhg) RR Sp02 Nadi Kulit Skala Koma Glasgow

Jam Menit
...................... x / Mnt Reguler Warna
Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C

...................... x / Mnt Reguler Warna

Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C

...................... x / Mnt Reguler Warna

Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C

...................... x / Mnt Reguler Warna

Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C
....... Thn / Bln / Hr

..... Jam : ..............

.............................................. Dokumen
..............................................
Hasil Lab dan Radiologi
etujui : ..........................................

............./ ................... WIB Tanggal /

.................. WIB
kembali
pasien

a, ……................ Keluhan
......................
.....................................

Heat stroke Apnoe

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

Peralatan

Monitor Infus Pump Syringe Pump

la Koma Glasgow
Eyes :
1. Tidak respon
2. Rangsang nyeri
3. Panggilan
4. Spontan

Verbal :
1. Tidak bicara
2. Tidak mengerti
3. Kacau
4. Bingung
5. Terarah
 Jam BP (mmhg) RR Sp02 Nadi Kulit Skala Koma Glasgow

Jam Menit

...................... x / Mnt Reguler Warna

Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C

...................... x / Mnt Reguler Warna

Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C

...................... x / Mnt Reguler Warna

Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C

...................... x / Mnt Reguler Warna

Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C

...................... x / Mnt Reguler Warna

Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C

...................... x / Mnt Reguler Warna

Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C

...................... x / Mnt Reguler Warna

Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C

...................... x / Mnt Reguler Warna

Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C

...................... x / Mnt Reguler Warna

Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C

...................... x / Mnt Reguler Warna

Kuat:........
Irregular Dingin/Hangat
Lemah E.... M.... V......
Kering/Basah Score : ..............
Suhu :......0C

Jam Obat-obatan Rute/ Dosis Urine Output Alergi

Jam Menit
Ya/ Tuliskan
……………………..
……………………..
……………………..
……………………..

Tidak ada

Perhatian khusus/ Catatan khusus

……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
 SERAH TERIMA PASIEN

TD : ………..mmHg Nadi : …………x/menit T : ……..….. 0C RR : ………….x/menit

GCS : E ……… M ……… V …….

Tulungagung, …………………………… Jam : ……..

Petugas Ambulan Petugas/ Keluarga Penerima*

(…………………………………………) (…………………………………………)
Tanda Tangan & Nama Terang Tanda Tangan & Nama Terang
la Koma Glasgow

Motorik :
6 Ikut perintah
5 Rangsang nyeri
4 Menghindar
3 Fleksi
2 Extensi
1 Tidak Respon

Alergi

Ya/ Tuliskan
……………………..
……………………..
……………………..
……………………..

Tidak ada

………………………
………………………
………………………
RR : ………….x/menit

erima*

………………)
ma Terang