n PEMERINTAH KABUPATEN KEPAHIANG

DINAS KESEHATAN
PUSKESMAS BATU BANDUNG
Alamat :Desa Batu Bandung Kecamatan Muara Kemumu

LAYANAN GAWAT DARURAT

NO RM

ALERGI

NAMA LENGKAP (TN/NY/ANAK) UMUR TANGGAL JAM MASUK JENIS KELAMIN

HARI / BLN / THN
ALAMAT :
PEKERJAAN :
CARA PEMBAYARAN : UMUM LAIN – LAIN : ………………………………………………………….
BPJS

CARA DATANG KE PELAYANAN : DATANG SENDIRI DIANTAR POLISI

BERSAMA KELUARGA LAIN – LAIN : ………………………………………………..

KASUS : KECELAKAAN BUKAN KECELAKAAN

KANAN KIRI

KANAN KIRI

KANAN KIRI
ANTERIOR POSTERIOR

KELUHAN UTAMA : _____________________________________________________________________________________

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

STATUS NEUROLOGIS : Vital Sign :

GCS : ______________ TD : ______________ mmHg
Nadi : ______________ x/ menit
REFLEKS PUPIL : ______________ RR : ______________ x/menit
Suhu : ______________ 0 celcius
PEMERIKSAAN UMUM :
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
PEMERIKSAAN PENUNJANG

KONSULTASI

DIAGNOSA KERJA : ______________________________________________ KODE ICD 10 : 1. _______________

DIFERENTIAL DIAGNOSA : ______________________________________________ 2. _______________
______________________________________________ 3. _______________
______________________________________________ 4. _______________
______________________________________________ 5. _______________
______________________________________________

TERAPI / TINDAKAN / PROSEDUR DI LAYANAN GAWAT DARURAT : KODE ICD 10 :

______________________________________________________________________ 1. _______________
______________________________________________________________________ 2. _______________
______________________________________________________________________ 3. _______________
______________________________________________________________________ 4. _______________
______________________________________________________________________ 5. _______________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

OBSERVASI
TANGGAL JAM TD N RR T CAIRAN KETERANGAN
MASUK KELUAR

Keadaan Keluar Dari Layanan Gawat Darurat

Pulang Jam Pulang : Pulang Atas Permintaan Sendiri/Keluarga
Meninggal Setelah Tiba Di Pueskesmas Batu Bandung Meninggal di LAYANAN GAWAT DARURAT
Rujuk Ke : ……………………………………..
Kontrol / Rawat Jalan

( AN : ………………………………………………………) ( AN : dr. _________________________)

Nama jelas dan tanda tangan perawat Nama jelas dan tanda tangan dokter