RUMAH SAKIT UMUM DAERAH KEPAHIANG Nama : ...................................................................................

L/P
Jalan lintas Kepahiang- Bengkulu Desa Tebat Monok No. RM : ..........................................................................................
Nomor 325 Telepon (0732)391425
Faximile (0732)391144KEPAHIANG 39172
Tgl. Lahir / Umum : ...........................................................................................
CHECKLIST PASIEN KELUAR Ruang Rawat : ..........................................................................................
RUANG RAWAT INTENSIF Tanggal Masuk : ..........................................................................................

. Nama DPJP : ...................................................... Nama PPJP : ......................................................................................................

Diagnosa : ..........................................................................................................................................................................................

Kriteria Pasien Keluar :

1. Kesadaran
GCS : E ………………. M ………………. V ……………….
2. Tanda Vital
TD : …………………….. mmHg MAP : ………………. mmHg HR : ………………. x/menit reguler /irreguler
RR : …………………….. x/menit SatO2 : ……………………..%, dengan alat bantu nafas
Canal nasal : …………………….. lt/menit
NRM : …………………….. lt/menit
ETT : …………………….. lt/menit
Tracheostomi : …………………….. lt/menit
3. Nilai Laboratorium
Glukosa : …………………….. mg/dl PH darah : …………………….. Natrium : …………………….. mEq/L
Ureum : …………………….. mg/dl Pa O2 : …………………….. mmHg Kalium : …………………….. mEq/L
Kreatinin : …………………….. mg/dl PC O2 : …………………….. mmHg
Lain-lain : ……………………..
4. Radiologi :

5. Elektrokardiogram : Normal / Abnormal ..........................................................................................................................................

6. Kondisi lain :

Menolak intervensi aktif ( menandatangani form penolakan tindakan )

Pasien dalam keadaan vegetative permanen
Pasien / keluarga menolak di rawat intensif
Lainnya :
.....................................................................................................................................................................................................

7. Masalah yang harus diperhatikan :

...............................................................................................................................................................................................................

...............................................................................................................................................................................................................

Kesimpulan :

Pasien datang dapat dipindahkan dari ruang rawat intensif : ICU, ICCU, Rawat Inap *)
Dipindah ke ruang : .........................................................................................................................................................................................

Kepahiang , Tgl. .................................. Jam ................ Kepahiang , Tgl. ........................ Jam .......................
DPJP ruang rawat intensif Dokter jaga intensif

(Tanda tangan & Nama Jelas) (Tanda tangan & Nama Jelas)

*) Coret yang tidak perlu