RUMAH SAKIT UMUM BUNDA THAMRIN

Nama :
Jln. Sei Batang Hari no. 28-30, Medan Baru
Telp. (061) 88813615 – 88813616 – 88813617 – 88813618 Tanggal Lahir :
Fax. 061 80501822 Jenis Kelamin :
No RM :
ASESMEN MEDIS
INSTALASI GAWAT DARURAT

TRIASE & PENGKAJIAN INSTALASI GAWAT DARURAT

TRIASE DIISI OLEH DOKTER
BERI TANDA ( ) PADA KOLOM YANG ANDA ANGGAP SESUAI DENGAN KONDISI PASIEN
Keluhan Utama: Tanggal: Kasus :

Jam : □ Trauma
□ Non trauma
Permintaan Visum: □ Tidak Ada □ Ada, Nomor Permintaan
:.....................................................................................................
Primary Survey:
Airway Breathing Circulation Disability/Neurological
□ Bebas □ Spontan Nadi: □ Kuat □ Lemah □ Alert
□ Gargling □ Tachipneu CRT : □ <2” □ >2” □ Verbal
□ Stridor □ Dispneu Warna Kulit : □ Respon to Pain
□ Wheezing □ Apneu □ Normal □ Unresponsive
□ Ronchi □ Pucat Pupil:
□ Kuning □ Isokor
Perdarahan : □ Stridor
□ Tidak Ada □ Pin Point Pupil
□ Terkontrol Diameter : /

□ Tak Terkontrol
Turgor Kulit: □ Baik □ Reflek Cahaya : /
Buruk
Status Alergi □ Tidak □ Ya, Sebutkan :
Golongan darah □ A □ B □ AB □ O □ Rhesus
Gangguan Prilaku □ Tidak Terganggu □ Ada gangguan : □ Tidak Membahayakan
□ Membahayakan
Skala Nyeri
(Intensitas Nyeri WONG BAKER FACE PAIN RATING SCALE DAN NUMERIC RATING SCALE/NRS)
Untuk anak > 6 tahun dan dewasa

Skala Flacc untuk anak <

6 tahun
Pengkajian 0 1 2 Nilai
Tersenyum/tidak ada Terkadang Sering menggetarkan
Wajah ekspresi khusus menangis/menarik diri dagu dan mengatupkan
dahi
Kaki Gerakan Tidak tenang/tegang Kaki dibuat
normal/relaksasi menendang/menarik diri
Tidur, posisi normal, Gerakan menggeliat, Melengkungkan
Aktivitas mudah bergerak berguling, kaku punggung
kaku/menghentak
Menangis Tidak menangis Mengerang, merengek- Menangis terus-
(bangun/tidur) rengek menerus/terisak/menjerit
Bersuara normal/tenang Tenang bila dipeluk, Sulit untuk ditenangkan
Suara digendong atau diajak
bicara
Total Skor :
Skala : 0 = nyaman 4-6 = nyeri
1-3 = kurang nyaman 7-10 = nyeri berat

KATEGORI TRIASE KETERANGAN RESPONSE TIME

□ Kategori 1 Resusitasi Segera (0 menit)
□ Kategori 2 Emergency / Gawat Darurat 10 Menit
□ Kategori 3 Urgent/ Darurat 30 Menit
□ Kategori 4 Semi Darurat 60 Menit
□ Kategori 5 Tidak Darurat 120 Menit
Keluhan Utama: Waktu : Kasus :
Tanggal periksa: □ Trauma
Jam Periksa : □ Non trauma
Permintaan Visum: □ Tidak Ada □ Ada, Nomor Permintaan :................................................................................ .......
PENGKAJIAN MEDIS
Pemeriksaan Dokter, Pukul :............:............
Subjective :.......................................................................................................................................................................
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Objective :
KU :
TTV Nadi :..........x/menit regular/irregular TD :............. /............. mmhg
Pernapasan :..........x/menit Suhu :......... 0C
SpO2 :......... %
Kepala :
Mata :
Mulut :
Leher :
Dada :
Abdomen :

Ekstrimitas:
Genital :

Kode gambar:
A : Abrasi U : Ulkus VA : Vulnus Appertum L : Lain-lain
C : Combustio H : hematoma D : Deformitas N : Nyeri
Pemeriksaan Penunjang :
□ Laboratorium :
Assassment:
□ Diagnosis Kerja :...................................................................................................... .........................................................
□ Diagnosis Banding :................................................................................................................................................................

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Planning : Penatalaksanaan/ Pengobatan/ Rencana Tindakan
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Manismata,.......................................

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Nama/ Tanda Tangan Dokter