UPTD.

RUMAH SAKIT PRATAMA GEMA SANTI NUSA PENIDA

Jl. Pendididkan, Br. Nyuh, Ds. Ped, Kec. Nusa penida, Kab. Klungkung

Nama :
Jenis kelamin :
Tgl lahir :
No. RM :
No. Dok : 12B/FORM/RM/2018

FORMULIR TRANSFER PASIEN ANTAR RS

No Rujukan .......................................... Nama RS Tujuan ................................................. . Nama Staf yang menyetujui ........................................
Ringkasan Awal Masuk
Keluhan Utama ............................................................................................................................. .......................................................................................
............................................................................................................................................. .......................................................................
............................................................................................................................................................. .......................................................

Riwayat Alergi : Obat Makanan Lainnya Nama Alergen : ..................................................................

Diagnosa Masuk : .................................................................... Tangga l MRS : ..................................................................
Diagnosa Sekarang : .................................................................... Tgl & Jam Tranfer : ...................................................................
DPJP Utama : .................................................................... Al asan dirujuk : ...................................................................
DPJP Pendamping : .................................................................... Kebutuhan Spesifik : ...................................................................

Pemeriksaan Diagnostik Yang Sudah Dilakukan

Laboratorium .............................................................................................................. ...............................................................................................
............................................................................................................................... ..............................................................................
Thoraks Foto Foto Abdomen Foto Cervical / Vertebral Foto Genu / Femur .................
EKG Echo / Treadmill CTG USG .......................................
Spirometri Endoscopy ........ CT Scan ......... .............. MRI ........................................
......................................... ........................... ................... ................... .................................................
Tindakan Medis Yang Telah Dilakukan
Cateter, Tgl ...................... NGT, Tgl ......................... WSD, Tgl ........................... IVFD, Tgl .................. CVC, Tgl .....................
.............................................................................................................................................................................. ..............................................................
............................................................................................................................................................................................. ...............................................
Pemberian Terapi
Program Cairan Infus : ...................................................................................................................................................................... ....................................
..................................................................................................................................................................................... .....................
Obat Injeksi Obat Oral Obat lainnya
1. .............................................. 1. ....................................................... 1. .......... .....................................................
2. .............................................. 2. ....................................................... 2. .................................................. .............
3. .............................................. 3. ...................................................... . 3. ...............................................................
4. .............................................. 4. ....................................................... 4. ...............................................................
5. .............................................. 5. ....................................................... 5. ...............................................................
6. .............................................. 6. ....................................................... 6. ......... ......................................................

Kondisi Pasien Saat Trasfer

Keadaan Umum Baik Lemah .................................
Kesadaran CM Apatis Delirium Somnolen Coma GCS E .......... V ........... M ..............
Tanda – tanda Vital TD : ......................mmHg
Suhu : ..................... oC
Nadi : .................... x/mnt Teratur Tidak Teratur
Pernafasan : .....................x/mnt
Lain – lain : .............................................................................................................................................................. ............................................................
................................................................................................................................................................................................... ...........................................
.................................................................................................................................................................................................................... ..........................

Yang Menyerahkan Mengetahui Yang Menerima

( ..............................................) ( DPJP/Dokter IGD/Dokter Ruangan) ( ...................................................)