RUMAH SAKIT PERMATA HATI

KOTA METRO
No. RM. :
RM
Jalan A.H.Nasution No.34-36 telp.(0725) 47874 Nama : (L/P)
Tgl. Lahir : 14
TRANSFER PASIEN ANTAR RUANGAN
Hari / Tanggal : ....................................................... Jam : ................ WIB Umum / Kontraktor / BPJS
Tanggal Masuk RS : ................................................. Jam : ................ WIB ASAL PASIEN
Dx Medis : ................................................. Ruangan : ............................................. Kelas : ..................
Dokter yang merawat : 1 .................................................................... Pindah ke ruangan : ............................. Kelas : ..................
2 .................................................................... Tiba di ruangan : ........................... WIB
3 ....................................................................
CARA PINDA
Brankar Kursi RodaH Jalan Digendong
Alasan Masuk / Pindah Rawat Inap :

Temuan penting / signifkan untuk disampaikan / pemeriksaan yang abnormal :

Diagnosa sekarang :

Tindakan medis yang sudah dilakukan :

PEMBERIAN THERAPI

Infus : ........................................................................
Obat Injeksi
Nama obat : Jam Pemberian :
1 ................................................................................. ................................. WIB
2 ................................................................................. ................................. WIB
3 ................................................................................. ................................. WIB
4 ................................................................................. ................................. WIB
Obat Oral
1 ................................................................................. 4 .................................................................................
2 ................................................................................. 5 .................................................................................
3 ................................................................................. 6 .................................................................................
Lain-lain

Kondisi saat pindah (Observasi terakhir pukul : ............... WIB)

Keadaan umum : .......................................... Kesadaran : .......................................... GCS : E-.......... M-.......... V-.......... = ..............
0
TD : ...................... mmHg Nadi : ...................... x/m Suhu : ...................... C Nafas : ...................... x/m
Intake : ...................... CC Output : ...................... CC Balance : ...................... CC
Therapy Oksigen : Tidak Ya Nasal Kanule ............ Liter Sungkup Rebreating NRM
Nyeri : Tidak Ya, Skor Nyeri : ...........
Resiko Jatuh : Tidak Ya, Skor Resiko
Jatuh : ........... Kewaspadaan : Kontak Droplet
Airbone
Perawat yang mengirim Perawat yang menerima

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Nama Jelas & Tanda Tangan ( ......................................... )
Nama Jelas & Tanda Tangan