KLINIK ANUGRAH NORMA SEJAHTERA (ANS)

Jl. Raya Bojonegoro - Cepu No. 1688 Desa Panjunan

Kecamatan Kalitidu Kabupaten Bojonegoro
Telp. (0353) 512260, Fax. (0353) 512220

FORM TRANSFER PASIEN ANTAR RUANGAN

Nama Pasien : ................................................................................... No. RM : .......................................................................
Tanggal Lahir : ..............................
SITUATION
DPJP :................................................................ Pendidikan : .........................................................
Tanggal Masuk RS :................................................................ Asal Ruangan : .........................................................
Agama :................................................................ Ke Ruangan : .........................................................
Tanggal Pindah : .......................... Jam ..............WIB

BACKGROUND
Keluhan Saat Masuk : ............................................................................................................................................................
Riwayat Alergi : □ Tidak ada □ Ada, .............................

ASSESSMENT

TTV : TD …......../…….... mmHg ; Temp ......... ; HR ........... x/mnt ; RR ......... x/mnt ; SpO2 :…………..%

GCS : ……………….….…... ; GDA ….......... mg/Dl ; Berat Badan .............. kg ; Tinggi Badan ............ cm
Penggunaan O2 : □ Tidak ada □ Ada, ......... lt/mnt via .................
Nyeri : □ Tidak ada □ Ada, skala ........ (numeric/wong baker)
Resiko Jatuh : □ Tidak ada □ Ada, tingkat resiko ..................... (morse/humpty dumpty)
Program Terapi : 1. IVFD ................................................................ 6. ..............................................................................
2. ........................................................................ 7. ..............................................................................
3. ........................................................................ 8 ...............................................................................
4……………………………………………………………………….. 9……………………………………………………………………………..
5……………………………………………………………………….. 10…………………………………………………………………………….
Alat Medis yang Terpasang :
1. IV line no. .......... Tgl pasang .......................... 3. NGT no. ....... Tgl pasang.......................................
2. Foley Catheter no. ...... Tgl pasang.................. 4. Lain-lain ............... Tgl pasang .............................
Tindakan Medis yang sudah dilakukan :
1. ........................................................................ 3. ..............................................................................
2. ........................................................................ 4. ..............................................................................
Pemeriksaan penunjang yang sudah dilakukan hari ini :
1. Laboratorium DPJP sudah terinfo □ Ya □ Tidak
2. Radiologi DPJP sudah terinfo □ Ya □ Tidak

RECOMMENDATION
Tindakan medis / keperawatan yang akan dilakukan :
1. ........................................................................ 3. ..............................................................................
2. ........................................................................ 4. ..............................................................................
Hal-hal yang harus diperhatikan :
1. ........................................................................ 3. ..............................................................................
2. ........................................................................ 4. ..............................................................................

Kalitidu , .................. Jam ........ WIB

Perawat yang menyerahkan Perawat yang menerima

(.............................................) (.............................................)