RUMAH SAKIT IBU DAN ANAK

DUREN TIGA LABEL IDENTITAS PASIEN

Jl. Duren Tiga Raya No. 5 Pancoran, Jakarta (Label Rawat Inap)
Selatan 12780 Phone. (021) 7993817, 7948696,
7976605, 7948697 Fax. (021) 7901050

RESUME TRANSFER PASIEN DARI UGD KE RUANGAN

Tanggal masuk :.................................. Jam : ..............................................
Tanggal Pindah :.................................. Jam :................................................
Pindah : dari UGD Dari ruang perawatan :.....................

A. Diisi oleh dokter

Diagnosis :......................................................................................................................................................
1. Triage : Satu ( I ) Dua ( II ), Tiga ( III ), Empat ( IV ), Lima ( V )
2. Riwayat singkat penyakit.............................................................................................................................
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3. Terapi diruangan/ ICU dan terapi selanjutnya:............................................................................................
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4. Masalah medis dan keadaan saat sakit :.....................................................................................................
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B. Diisi oleh perawat ( masalah keperawatan )
1. Tindakan perawat yang sudah dilakukan :...................................................................................................
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2. Masalah perawatan pada saat pindah : .......................................................................................................
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3. Rencana tindakan selanjutnya : ..................................................................................................................
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Perawat yang memindahkan & menerima Jakarta,....................................
Dokter

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Tanda tangan & nama jelas Tanda tangan & nama jelas