RSIA HARAPAN BUNDA NAMA : , L/P

Jl. Tukad Unda No. 1 Renon Denpasar – Bali

Telp. : (0361) 265533, 265534, Fax, : (0361) Tgl .Lahir : hr/bln/thn
265532
No. RM Pasien:
ASESMEN MEDIS TRAUMA INSTALASI GAWAT DARURAT
TGL ; …………………………………………………………………. JAM :
…………………………………………………………………………
Rujukan :  Ya, dari  RS .....................................  Puskesmas .......................................
 Dr .....................................  Lainnya ...........................................
Dx. Rujukan ..............................................................................................................
 Tidak,  Datang sendiri  Diantar oleh ....................................
Nama keluarga yang bisa dihubungi : .................................................. Telp: ......................................
Alamat : ..................................................................................................
Transportasi waktu datang :  Ambulance 118  Ambulans lain ......................  Kend. Lainnya ......................
Tanda Tangan Dokter
Dokter yang memeriksa : ..................................................
Supervisor Jaga : ..................................................

KELUHAN UTAMA Skala Nyeri



INFORMASI PREHOSPITAL
 Kecelakaan Lalu Lintas :  Pejalan kaki
 Sepeda gayung
 Sepeda motor
 Mobil
X .............................................................
X .............................................................
X .............................................................
X ............................................................. ICD X ............................

 Kecelakaan lainnya :  Jatuh ........... meter  Pohon  Gedung  Lainnya ...................

 Luka Tembak  Luka Tusuk
 Luka hancur (crushed)  Luka bakar
Lainnya ...................................................... ICD X ............................
Mekanisme kecelakaan :  Mobil :  Pengemudi  Penumpang
Memakai sabuk pengaman :  Ya  Tidak
 Sepeda motor :  Pengemudi  Penumpang
Memakai helm :  Ya  Tidak

Tanggal kejadian : ....... / ...... ./ ......., Pukul : ...... : .......Wita Tempat kejadian : ...........................................

RIWAYAT AMPLE
 Alergi : ....................................................................................................................................................................................
 Medikasi : .................................................................................................................................................................................
 Penyakit lain/penyerta : .............................................................................................................................................................
 Makan terakhir, jam : ...... : ........ Wita , Pengaruh NAPZA :  Tidak  Ya, jenis ..........................................................
 Suntikan Anti Tetanus terakhir : ..............................................
 Hamil :  Tidak  Ya: Umur kehamilan : ............. bulan  Menstruasi terakhir : ................................
 Kejadian-kejadian yang lain : ....................................................................................................................................................

TINDAKAN PREHOSPITAL
 C-Spine Protection :  Tidak  Ya ..............................  Airway device :  Tidak  Ya ......................................
 IV Line :  Tidak  Ya ..............................  Medications :  Tidak  Ya ......................................
 Lain-lain : ....................................................................................................................................................................................
PRIMARY SURVEY TRAUMA SCORE
A. Airway A. Frekwensi Pernafasan
 Bebas  Tersumbat  10 – 25  4
 Trachea di tengah:  Ya  Tidak  25 – 35  3
 > 35  2
 Resusitasi : .............................................................  < 10  1
 Re-evaluasi: .............................................................  0  0

B. Usaha bernafas
 Normal  1
 Dangkal  0
B. Breathing C. Tekanan darah
 Dada simetris :  Ya  Tidak  > 89 mmHg  4
 Sesak nafas :  Ya  Tidak  70 – 89 mmHg  3
 Respirasi ...............x/mnt  50 – 69 mmHg  2
 Krepitasi :  Ya  Tidak  1 – 49 mmHg  1
 Suara nafas :  0 0
- Kanan :  Ada :  Jelas  Menurun  Ronchi D. Pengisian kapiler
 Wheezing,  Tidak Ada  < 2 dtk  2
- Kiri :  Ada :  Jelas  Menurun  Ronchi  > 2 dtk  1
 Wheezing,  Tidak Ada  Tidak ada  0
 Saturasi O2 : ............. %
pada:  Suhu ruangan  Nasal canule E. Glasgow Coma Score (GCS)
 NRB  Lainnya .......................  14 – 15  5
 11 – 13  4
 Assesment : .............................................................  8 – 10  3
 Resusitasi : .............................................................  5–7  2
 Re-evaluasi: .............................................................  3–4  1

C. Circulation TOTAL TRAUMA SCORE (A+B+C+D+E) = ...................

 Tensi : .........../.......... mmHg
 Nadi : ................x/mnt
 Kuat  Lemah  Regular  Irregular REAKSI PUPIL
 Suhu Axilla : ............ ºC Suhu Rectal : ............ºC Kanan Ukuran (mm) Kiri Ukuran (mm)
 Temperatur kulit :  Hangat  Panas  Dingin  Cepat  .........  .........
 Gambaran kulit :  Normal  Kering  Konstriksi  .........  .........
 Lembab/basah  Lambat  .........  .........
 Dilatasi  .........  .........
 Assesment : .............................................................  Tak bereaksi  .........  .........
 Resusitasi : .............................................................
 Re-evaluasi: .............................................................

D. Disability
 Alert
 Verbal response
 Pain response
 Unresponsive

SECONDARY SURVEY

 Kepala : ..................................................................................................................................................................
..................................................................................................................................................................
 Maxillofacial : ..................................................................................................................................................................
..................................................................................................................................................................
 C-Spine/neck : ..................................................................................................................................................................
..................................................................................................................................................................
 Chest : ..................................................................................................................................................................
..................................................................................................................................................................
 Abdomen : ..................................................................................................................................................................
..................................................................................................................................................................
 Genital-Perineum : ..................................................................................................................................................................
 ..................................................................................................................................................................
 Rectal Toucher : ..................................................................................................................................................................
..................................................................................................................................................................

 Musculoskeletal :
Inspeksi ;
Kulit ;
Otot dan tendon:
Tulang :
Massa :
Palpasi :
Suhu :
Nyeri :
Massa :
Arteri (pulsasi):
Vena ( Cappilary refill):
Saraf (Sensibilitas):
Gerakan
Regio
Abnormal
Aktif Fleksi / Ekstensi /
Derajat Abduksi / adduksi
Rotasi interna / eksterna
Pasif Fleksi / ektensi
Derajat Abduksi / adduksi
Rotasi interna / eksterna

Pemeriksaan khusus

Status neurologis
Sensoris :
Motoris :
Reflek fisiologis:
Reflek patologis:
 NAMA : , L/P No. RM pasien:
RM BEDAH
UMUR : hr/bln/thn
PENOMORAN LOKASI LUKA
1. Laserasi 2. Abrasi 3. Hematoma 4. Kontusio
5. Dislokasi 6. Fr. Terbuka 7. Luka tembak 8. Luka tusuk
9. Luka bakar 10. Luka dingin 11. Edema 12. Amputasi
13. Avulsi 14. Nyeri 15. Fr. Tertutup 16. Lain-lain .........................................
RENCANA KERJA HASIL PEMERIKSAAN PENUNJANG

DIAGNOSA ICD-X TERAPI

HASIL PEMBEDAHAN

DIAGNOSA AKHIR

DISPOSISI
 Hidup:  Boleh pulang, Jam Keluar: ................ Wita Tanggal : .................................
Kontrol Poliklinik  Ya, ................................. Tanggal : .................................,  Tidak
 Dirawat di ruang:  Intensif  Ruang : .............................. Kelas ..................
 Mati:  Death on Arrival
 Setelah resusitasi Jam ............................. Wita Tanggal : .................................
Penyebab kematian : ..............................................................................................................................................

REKOMENDASI (SARAN) CATATAN PENTING