PT.

CAHAYA SEHAT LESTARI

RUMAH SAKIT KHUSUS BEDAH BUDI KASIH
Jalan Siliwangi KM. 7 No. 84 Majalengka 45459
Telp. (0233) 88665508 - Fax. (0233) 8665509
E-mail: rsbk.budikasih@gmail.com

FORMULIR TRANSFER PASIEN

Nama Pasien : ......................................................................................... Jenis Kelamin :L/P
Tanggal : ......................................................................................... Tanggal Masuk : .......................................................
Lahir DPJP : ......................................................................................... Ruang / Kamar : .......................................................
Dokter Konsulen 1 : ......................................................................................... Tanggal / Jam : .......................................................
Pindah
Dokter Konsulen 2 : ......................................................................................... Pindah ke Ruang / Kamar :
.......................................................
Diagnosis : ......................................................................................... Diagnnosis Sekarang : .......................................................
Masuk

I. RINGKASAN RIWAYAT PASIEN

Anamnesis
Keluhan utama : ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
Riwayat penyakit : ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
Pemeriksaan Fisik : ...............................................................................................................................................................................................................
Pemeriksaan tanda-tanda vital : Tensi : mmHg Suhu : 0
C Nadi : x/mnt
Keadaan umum : ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
Alasan transfer
: ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
II. PEMERIKSAAN PENUNJANG YANG SUDAH DILAKUKAN
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
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III. TINDAKAN MEDIS YANG SUDAH DILAKUKAN
.............................................................................................................................................................................................................................................................
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IV. PEMBERIAN TERAPI
Infus : ..............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

Obat Injeksi :
1. ...................................................................................................................
4. ...................................................................................................................
2. ...................................................................................................................
5. ...................................................................................................................
3. ...................................................................................................................
Obat Oral : 6. ...................................................................................................................

1. ...................................................................................................................
5. ...................................................................................................................
2. ...................................................................................................................
6. ...................................................................................................................
3. ...................................................................................................................
7. ...................................................................................................................
4. ...................................................................................................................
8. ...................................................................................................................
Derajat kebutuhan perawatan pasien
Derajat 0
Derajat 2
Derajat 1
Derajat 3
KATEGORI PASIEN TRANSFER
Level Kategori Pendamping Peralatan
Derajat 0 Pasien membutuhkan ruang TPK / Petugas keamanan Semua rekam medik,
perawatan biasa. hasil pemeriksaan penunjang,
format transfer internal
Derajat 1 Pasien beresiko mengalami perburukan, Petugas PK I Peralatan derajat 0+ tabung oksigen
pasien baru pindah dari / Petugas keamanan dan canul, stand infus dan pulse
HCU/ICU, pasien yang akan oksimetri.
dirawat diruang perawatan tim
perawatan khusus.
Derajat 2 Pasien memerlukan pengawasan Dokter/Perawat PK II Peralatan derajat 1, + bedside
ketat atau intervensi khusus, mis : pada monitor, syringe pump.
pasien yang mengalami kegagalan satu
sistem organ.
Derajat 3 Pasien mengalami kegagalan multi organ Dokter/Perawat PK III Peralatan derajat 2, + alat bantu nafas.
dan memerlukan bantuan hidup jangka
panjang ditambah dengan kebutuhan akan
alat bantu nafas.

V. KONDISI PASIEN
Sebelum Transfer Setelah Transfer
Keadaan umum : ...................................................................................... Keadaan umum : ......................................................................................
Kesadaran : ...................................................................................... Kesadaran : ......................................................................................
Pemeriksaan tanda-tanda vital : Pemeriksaan tanda-tanda vital :
Tensi : mmHg Tensi : mmHg
Suhu : 0
C Suhu : 0
C
Nadi : x/mnt Nadi : x/mnt
Catatan penting : ...................................................................................... Catatan penting : ......................................................................................
...................................................................................... ......................................................................................
...................................................................................... ......................................................................................
...................................................................................... ......................................................................................
Petugas yang menyerahkan Petugas yang menerima

Petugas Medis Petugas Medis

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