KLINIK PRATAMA DADI WARAS

Jln. Raya Pati – Purwodadi KM. 17 email : klinikdadiwaras@gmail.com

Form Gawat Darurat
REKAM MEDIS PASIEN GAWAT DARURAT NOMOR REKAM MEDIS ......................................

Nama Paisen : ................................................................................... Jenis Kelamin : □ Laki – laki □ Perempuan

Pekerjaan Pasien : ..........................................................................................................................................................................
Tgl lahir pasien : ......................................... Umur ..............Th/Bln/Hr. Agama .........................................................................
Nama KK : ..........................................................................................................................................................................
Alamat : Dusun : .............................................................................................................................................................
Desa/Kel. : .......................................Kec. : .............................................. Kota/Kab.:.....................................

Jenis Pasien : □ Askes □Jamkesmas □ Jamkesda □ Jamkesos □ Umum

Rujukan : □ Ya Dari □ RS ........................................................ □ Puskesmas ..........................................................
□ Dokter ................................................... □ Lainnya ..............................................................
Rujukan : □ Tidak □ Datang Sendiri
□Diantar oleh :
Pengantar : Nama : ...........................................................................................................................................
Alamat : ...........................................................................................................................................
Penyebab Cedera / □ Kecelakaan Lalu lintas (KLL) .................................................................................................
Keracunan □ Lainnya : .................................................................................................................................
Tanggal Kejadian : ................................................
Tiba di Klinik Tanggal : ................................................

Transportasi waktu datang : □ Ambulans 118 □ Ambulans Lain □ Kendaraan Lainnya ..........................
ALERGI TERHADAP

*PETUGAS TRIASE : .................................................................................................................................

1. DIPERIKSA DOKTER : Tanggal: ..............................................Pukul: ................................................WIB

2. JENIS KASUS : □ Trauma □ Non Trauma

□ Umum □ Anak □ Obsgyn
□ Lainnya
3. ANAMNESA DAN PEMERIKSAAN FISIK
a. Anamnesa : ................................................................................................................................
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: ...............................................................................................................................
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b. Pemeriksaan Fisik KU : .........................................................................................................................
Kesadaran/ GCS : ....................................................................................................

Tindakan Resusitasi □ Ya □ Tidak

□Tensi : .................. □ Nadi .................. □ Suhu .................□ Nafas..................
□Berat Badan :................................kg □ Tinggi Badan : ...........................cm
Belakang Depan
Beri tanda “X” pada □ yang perlu

Jenis/ Macam Pemeriksaan

c. Pemeriksaan Penunjang : ................................................................................................................................
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4. DIAGNOSA KERJA : ...............................................................................................................................

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5. TERAPI / TINDAKAN
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6. TINDAK LANJUT
□ Dipulangkan untuk kontrol berobat pada Klinik : .......................................................Tgl : ..................................
□ Dirawat di Bangsal : ..........................................Kamar No : ......................................
□ Meninggal Dunia : Hari : ...................................Tanggal : .................................... Pukul : ...........................WIB
□ Dikirim/dirujuk ke RS : ..........................................................................................................................................
□ Keluar UGD, pukul : ................................WIB

7. CATATAN LAIN : .......................................................................................................................................................

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 Petugas UGD

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