RUMAH SAKIT

SARI ASIH
FORMULIR TRANSFER PASIEN
Nama Pasien : ......................................................................................... Jenis Kelamin : L/P
Tanggal Lahir : ......................................................................................... Tanggal Masuk : .......................................................
DPJP : ......................................................................................... Ruang / Kamar : .......................................................
Dokter Konsulen 1 : ......................................................................................... Tanggal / Jam Pindah : .......................................................
Dokter Konsulen 2 : ......................................................................................... Pindah ke Ruang / Kamar : .......................................................
Diagnosis Masuk : ......................................................................................... Diagnnosis Sekarang : .......................................................

I. RINGKASAN RIWAYAT PASIEN

Anamnesis
Keluhan utama : ...............................................................................................................................................................................................................
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Riwayat penyakit : ...............................................................................................................................................................................................................
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Pemeriksaan Fisik : ...............................................................................................................................................................................................................
0
Pemeriksaan tanda-tanda vital : Tensi : mmHg Suhu : C Nadi : x/mnt
Keadaan umum : ...............................................................................................................................................................................................................
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Alasan transfer : ...............................................................................................................................................................................................................
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II. PEMERIKSAAN PENUNJANG YANG SUDAH DILAKUKAN
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III. TINDAKAN MEDIS YANG SUDAH DILAKUKAN
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IV. PEMBERIAN TERAPI
Infus : ..............................................................................................................................................................................................................................................
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Obat Injeksi :
1. ...................................................................................................................
2. ...................................................................................................................
3. ...................................................................................................................
Obat Oral :
1. ...................................................................................................................
2. ...................................................................................................................
3. ...................................................................................................................
4. ...................................................................................................................
Derajat kebutuhan perawatan pasien
Derajat 0
Derajat 1
4. ...................................................................................................................
5. ...................................................................................................................
6. ...................................................................................................................
5. ...................................................................................................................
6. ...................................................................................................................
7. ...................................................................................................................
8. ...................................................................................................................
Derajat 2
Derajat 3
KATEGORI PASIEN TRANSFER
Level Kategori Pendamping Peralatan
Derajat 0 Pasien membutuhkan ruang TPK / Petugas keamanan Semua rekam medik,
perawatan biasa. hasil pemeriksaan penunjang,
format transfer internal
Derajat 1 Pasien beresiko mengalami perburukan, Petugas PK I Peralatan derajat 0+ tabung oksigen
pasien baru pindah dari HCU/ICU, / Petugas keamanan dan canul, stand infus dan pulse
pasien yang akan dirawat diruang oksimetri.
perawatan tim perawatan khusus.
Derajat 2 Pasien memerlukan pengawasan Dokter/Perawat PK II Peralatan derajat 1, + bedside
ketat atau intervensi khusus, mis : pada monitor, syringe pump.
pasien yang mengalami kegagalan satu
sistem organ.
Derajat 3 Pasien mengalami kegagalan multi organ Dokter/Perawat PK III Peralatan derajat 2, + alat bantu nafas.
dan memerlukan bantuan hidup jangka
panjang ditambah dengan kebutuhan
akan alat bantu nafas.

V. KONDISI PASIEN
Sebelum Transfer Setelah Transfer
Keadaan umum : ...................................................................................... Keadaan umum : ......................................................................................
Kesadaran : ...................................................................................... Kesadaran : ......................................................................................
Pemeriksaan tanda-tanda vital : Pemeriksaan tanda-tanda vital :
Tensi : mmHg Tensi : mmHg
0 0
Suhu : C Suhu : C
Nadi : x/mnt Nadi : x/mnt
Catatan penting : ...................................................................................... Catatan penting : ......................................................................................
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Petugas yang menyerahkan Petugas yang menerima

Petugas Medis Petugas Medis

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