RSUD Dr.

CHASAN BOESOIRIE TERNATE

FORMULIR TRANSFER PASIEN INTRA RS.

Nama Pasien …………………… No. Rekam Medik :…………………………………

TGL lahir/Umur ……………………… No Register :…………………………………
DPJP : ………………………Tanggal Masuk :…………………………………
Dokter Konsulen 1 :................................... Ruang/Kamar :…………………………………
Dokter Konsulen 2 :................................... Tanggal & Jam Pindah :…………………………………
Diagnosa Masuk ……………………… Pindah Ke Ruang/ Kamar :…………………………………
Diagnosa Sekarang ……………………….
I. PEMERIKSAAN FISIK
1 Keadaan Umum : ………………………………………………………………………………..
2 Kesadaran : ……………………………………………………………………………………..
3 Pemeriksaan Tanda-Tanda Vital : Tensi :……mmHg, Suhu:…C, Nadi:…..x/mnt
4 Keluhan :............................................................................................................................ ...........
5 Riwayat Penyakit...........................................................................................................................
6 Riwayat Alergi...............................................................................................................................
7 Alasan pindah ruangan:..................................................................................................................
II.PEMERIKSAAN DIAGNOSTIK YANG SUDAH DILAKUKAN
Laboratorium:............................................................................................................................ ....
............................................................................................................................. ........................
EKG Foto Abomen CT Scan:................................
Toraks Foto Spirometri Endoscopi:.............................
Foto Cervical/Vetebra Echo/ Treadmill CTG
Foto Genu/Femur USG/ MRI/A
Lain :..............................................................................................................................................
................................................................................................................ ......................................
II.TINDAKAN MEDIS YANG SUDAH DILAKUKAN
............................................................................................................................. .........................
............................................................................................................................. .........................
III. PEMBERIAN THERAPI
1 Infus : ............................................................................................................................. ....................................
2 Obat Injeksi:
1. ............................................................... 4. ......................................................................
2. ............................................................... 5. ......................................................................
3. ................................................................. 6. ......................................................................
3 Obat Oral:
1. ............................................................... 5. ......................................................................
2. ............................................................... 6. ......................................................................
3. ................................................................. 7. ......................................................................
4. ............................................................... 8. ......................................................................
4 Lain :..............................................................................................................................................
......................................................................................................................................................

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