TRIASE DAN PENGKAJIAN AWAL

PASIEN KEBIDANAN & KANDUNGAN

DATA : PASIEN SUAMI

Nama : .................................................................. ..................................................................
Umur : .................................................................. ..................................................................
Pekerjaan : .................................................................. ..................................................................
Agama : .................................................................. ..................................................................
Suku/Bangsa : .................................................................. ..................................................................
Alamat : ........................................................................................................................................
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TRIASE
Tanggal Kunjungan : Pkl :

Cara masuk :
□ IRJ □ IGD □ Dokter pribadi □ Langsung kamar bersalin
□ Datang Sendiri , Diantar Oleh : …………………………………………………………………………………
□ Rujukan dari : □ Puskesmas □ RB □ RSUD : ……………………………………………………………..
□ Dikirim oleh Polisi : ……………………dengan / Tidak disertai permintaan Visum et repetum

I. ANAMNESE
1. Keluhan Utama
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2. Riwayat Penyakit Sekarang :
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OBYEKTIF Keadaan Umum : Tekanan Darah : ……………………mm Hg
Kesadaran :……………………………. Frekuensi Nadi : …………………….x / Menit
GCS : ……… (E …M…V…..) Frekuensi Nafas : …………………...x / Menit
Berat Badan :………Gram Tinggi Badan : ……… .Cm Suhu : …………………….°C
AIR WAY □ Bebas □ Benda Asing □ Sputum □ Darah □ Lidah
BREATHING □ Tachipneu □ Bradipneu □ Hiperventilasi □ Orthopneu □ Apneu
- Bunyi nafas : □ Wheezing  □ Stridor
- Irama Pernafasan : □ Teratur □ Tidak Teratur
- Pengembangan Paru : □ Menurun  □ Retraksi dada
- Penggunaan Otot Bantu Nafas : □ Bahu diangkat □ Pernafasan dada
□ Cuping Hidung □ Pernafasan perut
CIRCULATION Pengisian Kapiler : □ 3< detik □ > 3 detik
Ekstremitas : □ Akral dingin □ Akral hangat □ Pucat □ Sianosis
ASESMEN Kategori Pasien : □ Emergent / Darurat □ Urgent / Mendesak □ Non Urgent /Tidak Mendesak
TRIASE
3. Riwayat Penyakit Dahulu
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4. Riwayat Operasi
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5. Riwayat Perkawinan
Perkawinan yang ke : ............... Lama perkawinan sekarang : .................. Tahun
6. Riwayat Obstetri
No Kehamilan / Partus Umur Keadaan Anak Keterangan
1
2
3
4
5
6
7
8
7. Kehamilan sekarang
HPHT : ............................................................................................................................................................................................

8. Riwayat ANC