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Nama Lengkap Pasien : .........................................

Tanggal Lahir : .........................................


Jl.Raya. Kosambi-Telagasari Km 3 Klari - Karawang (41371)
Telepon (0267) 437507 Fax (0267) 438681
Email :rs_citrasarihusada@yahoo.co.id Website : www.rscitrasarihusada.com
No. Rekam Medis :
SERAH TERIMA / HAND OVER
RAWAT INAP DENGAN KAMAR OPERASI

Asal Unit / Ruangan : .............................................. Rencana Tindakan : .................................................

DPJP/ Dokter Operator : dr. ................................... Dokter Anastesi : dr. ...............................................


Diagnosa Medis : ..................................................... Klinis Pasien :
.................................................................................. TTV
Diagnosa Keperawatan : ......................................... TD : ......../........ mmHg Nadi : ......... kali / menit
.................................................................................. RR : .......... kali / menit Suhu : ............... celcius
Keadaan Umum : ..................................................... TB : .................... cm BB : ............... kg
GCS : E ...... V ...... M ....... Total : ..................... Terpasang Alat invasif : ...........................................
Instruksi Terakhir : .................................................................................
O2 : Tidak Terpasang / Ya : ........lpm ...................... Kelengkapan Adminstrasi Status :
Infus : ........................................................................ - Persetujuan Operasi - Persetujuan Anastesi
Terapi Injek : Oral : - Form penandaan lokasi Operasi
- .................................... - .................................. - ...................................... - ...................................
- .................................... - .................................. Catatan-catatan : ....................................................
- .................................... - .................................. ..................................................................................
Nama & Paraf Petugas : Tanggal / Jam : .................... / ...... : ......
Yang Menyerahkan Nama & Paraf :
( .............................. ) Petugas Menerima ( .............................. )

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