RM ...

Nama Pasien : ...................................... No. RM :

Jenis Kelamin: L / P Tgl Lahir : ........................../....... Thn /

Bln / Hr

FORMULIR CATATAN
Ruang / Unit AMBULANS DAN EVAKUASI
: ......................................

Alamat
A. Permintaan Ambulans Internal : ......................................................... .......................................................
Nama Pasien Dokter Penanggung Jawab : .................................................................
: ............................................................................... Asal Ruangan
No RM : ............................................................................... : ................................................................
Diagnosa Rujukan : ............................................................................... Alasan rujuk / pindah : ................................................................
Tanggal / Jam permintaan Dokumen yang disiapkan
: ............................................/.......................... Wib : ................................................................
Tanggal / Jam berangkat Resume Medis/ Rujukan Hasil Lab dan Radiologi
: ............................................/..........................
B. Permintaan Ambulans External Wib Nama petugas RS tujuan yang menyetujui : ..........................................

Nama Pasien : ........................................................................... Tanggal / Jam berangkat

Umur / Jenis kelamin : ........................................................................... : ..................................../ ...................Wib
No. Telp yang menghubungi : ........................................................................... Tanggal / Jam Tiba di rs..
Alasan Penjemputan : ........................................................................... : ..................................../ ...................Wib
Tanggal / Jam permintaan : ............................................./ .....................Wib Ceck kebenaran telp dengan menghubungi kembali
Sarana Evakuasi Ceck ketersediaan ruangan sesuai indikasi pasien
Ambulans Non Ambulans .............................................
Petugas Evakuasi
1. .................................................. 3. ....................................................
2. .................................................. 4. ....................................................
Alasan Trasnportasi
Rujuk ke RS ........................... Pindah ke RS ........................... PAPS Dipulangkan Lainya, sebutkan.............
Keluhan Utama : .........................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................
TRIAGE
Merah Kuning Hijau Hitam
Jenis Transportasi
Emergency Non Emergency
SURVEI PRIMER Jam : ....................
Airway Breathing Exposure
Patent Spontan Luka terbuka
Obstruksi Total Tachypnoe Benda asing yang menancap
Obstruksi Pasrsial Kusmaul Hipotermia
Bradypnoe Heat stroke
Apnoe
DAFTAR MASALAH / KONDISI KHUSUS : ...........................................................................................................................................................................
.........................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................
INTERVENSI Jam : .............
Airway Breathing Circulation Exsposure Peralatan
......
Oropharyngeal Tube Nasal Canule ...................Lpm IVFD ( Jenis Cairan ) Bebat tekan Monitor
Endo Tracheal Tube Simpel Mask ...................Lpm ...................Tpm/..........cc Bidai Infus Pump
Nasopharingeal Tube Non Rebreathing Mask....Lpm ...................Tpm/..........cc Immobilasi Penuh Syringe Pump
Lain-lain................ Rebreathing .....................Lpm ...................Tpm/..........cc Cegah hipotermia
.................................... Venturi Mask ..................Lpm Folley Cath No..... Cervical collar
Lain-lain ................................ NGT No............... Lain-lain........

Isi dengan tanda ( √ ) dalam kotak sesuai dengan indikasi

CATATAN OBSERVASI
Jam
BP (mmhg) RR Sp02 Nadi Kulit Skala Koma Glasgow
Jam Menit

...................... x / Mnt Warna Dingin/Hangat E.... M.... V...... Eyes :

Reguler Kuat :........ Kering/Basah Score : .............. 1. Tidak respon
Irregular 2. Rangsang nyeri
Lemah Suhu 3. Panggilan
0
...................... x / Mnt :......
Warna C Dingin/Hangat E.... M.... V...... 4. Spontan
Reguler Kuat :........ Kering/Basah Score : ..............
Irregular
Lemah Suhu Verbal :
...................... x / Mnt Warna
:...... 0
C Dingin/Hangat E.... M.... V...... 1. Tidak bicara
Reguler Kuat :........ Kering/Basah Score : .............. 2. Tidak mengerti
Irregular 3. kacau
Lemah Suhu 4. Bingung
...................... x / Mnt Warna
:......0C Dingin/Hangat E.... M.... V...... 5. Terarah
Reguler Kuat :........ Kering/Basah Score : ..............
Irregular
Lemah Suhu
:......0C