DETASEMEN KESEHATAN WILAYAH IM 04.

01
RUMAH SAKIT TK IV IM 07.01

Nama :
CATATAN PEMINDAHAN PASIEN Tgl.Lahir/Umur :
ANTAR RUANGAN No.RM :
*Harap diisi atau di tempelkan stiker bila ada
SITUATION

Tiba diruangan ............................................. dari Ruangan ..................................

Tanggal : ......................... Pukul : .....................Wib
Dokter yang merawat :
1) dr. ..................................................
2) dr. ..................................................
3) dr. ..................................................
Pasien/Keluarga sudah dijelaskan mengenai diagnosis: Ya Tidak
Prosedur pembedahan/invasi yang akan/sudah dilakukan:
..............................................................................................................................................................
Tanggal : ..........................
Masalah Keperawatan utama saat ini :
..............................................................................................................................................................
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BACKGROUND

Riwayat alergi/reaksi obat: Tidak Ya, nama obat ..................................................................

Riwayat reaksi : ...................................................................................................................................
Intervensi medik/keperawatan : ...........................................................................................................
Hasil Investigasi abnormal : ................................................................................................................
Kewaspadaan/precautio : Standart Contact Airbone Droplet
ASSESSMENT

Observasi terakhir pukul : .............. Tingkat kesadaran : ................ Depresi Demensia Confuse
GCS : .................... (E/M/V) Pupil & Reaksi Cahaya : Kanan ......................... Kiri ..........................
TD : ...........mmHg, N : .........x/i Teratur/tidak teratur, RR : ........x/i, Suhu : ........C, Skala nyeri : .......
SpO2 : ..........%
Diet Nutrisi : Oral NGT Batasan cairan : .............cc Diet khusus, jelaskan ....................
Puasa jam : .....................
BAB : Normal Ileustomy/colostomy Inkontinesia alvi Lainnya : ......................................
BAK : Normal Inkotinensia Urine
Kateter, Jenis Kateter .................., No.Kateter : ..........., Tgl. Pemasangan : .......................
Mobilisasi : Jalan Duduk Tirah Baring
Transfer/mobilisasi : Mandiri Dibantu Sebahagian Dibantu penuh
Alat bantu yang digunakan : Tanpa alat bantu Gigi Palsu Kaca mata
Alat Bantu Dengar Lain- lain .........................
Luka/Perawatan Decubitus : Tidak Ya, Kondisi ................... Lokasi ................. Ukuran...........
Infus/CVC PIVAS Score.............................Tanggal Pemasangan ..............................

RM 29/Rev00/RI/2019
DETASEMEN KESEHATAN WILAYAH IM 04.01
RUMAH SAKIT TK IV IM 07.01

Tindakan/Kebutuhan Khusus : Protokol resiko pasien jatuh Protokol Restraint

Perawatan Luka Hygiene

Peralatan Khusus yang di perlukan :

1. .................................................................................... Lama penggunaan : ..................................
2. .................................................................................... Lama penggunaan : ..................................
3. .................................................................................... Lama penggunaan : ..................................

Hal-hal istimewa yang berhubungan dengan kondisi pasien :

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

Diagnosa Keperawatan : Sudah teratasi : Belum teratasi :

1. ..............................................................
2. ..............................................................
3. ..............................................................

RECOMENDATIONS

Konsultasi : .........................................................................................................................................

Rencana Pemeriksaan Lab/Radiologi : ..............................................................................................

Therapy : ............................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
Fisioterapi/mobilisasi : ........................................................................................................................
Persiapan pulang : .............................................................................................................................
Rencana tindakan lebih lanjut : ..........................................................................................................
Note : Obat, barang, dan dokumen yang disertakan
Obat-obatan MRI : ....... Lembar ECHO : ..................
Hasil Lab : ......... Lembar MRA : ....... Lembar Gigi palsu : ..................
Foto Rontgen : ........ Lembar Hasil USG : .......... Lembar Kaca Mata : ............
CT scan : ......... Lembar Alat bantu dengar : .............
Lain-lain: .................................

Disetujui Mengetahui Diserahkan Diterima

Pasien/ Keluarga Dokter yang merawat Perawat Perawat

DETASEMEN KESEHATAN WILAYAH IM 04.01
RUMAH SAKIT TK IV IM 07.01