Nama Pasien :………………………………………

RUMAH SAKIT MEDINA Rekam Medis :………………………………………

Alamat: Jalan Raya Wanaraja No. 500 Kecamatan
Wanaraja, Kabupaten Garut Tanggal Lahir :………………………………………
Tel : 0262-2448808 Alamat :
Email : rsmedinagarut@gmail.com

FORM TRANSFER PASIEN INTERNAL/EXTERNAL

Tanggal : ………………………………………………………………… Pukul : ………………………… WIB
Kepada Yth.
……..............................
Di .................................

Kami kirimkan pasien :

Nama : ..................................................................................................................................................
Tanggal lahir : ................................................................................. L/P*) Terpasang Gelang Identitas
Alamat : .................................................................................................................................................
No. RM : .................................................................................................................................................
Asal Ruangan/klinik : .................................................................................................................................................
Cara bayar : ..................................................................................................................................................
Diagnosa utama : .................................................................................................................................................
Diagnosa Sekunder : .................................................................................................................................................
Skala Nyeri (1-10) : ......................................................................... / 10 (Visual Analog Scale)
Alasan Transfer : Alih rawat ke ................................................................................................................................
Pemeriksaan penunjang yang akan dilakukan : ...........................................................................
.......................................................................................................................................................
Tindakan yang akan dilakukan : ...................................................................................................

Peralatan yang digunakan pasien : Oksigen Kateter Suction Ventilator

NGT Pompa infus Valve mask B ag ..................
Metode transfer : kursi roda Brankar Tempat tidur .................
Kendaraan yang digunakan : Mobil Pesawat Kapal Laut ..................
Risiko jatuh : Rendah Sedang Tinggi .................
Kelengkapan dokumen : Rekam Medis Foto Rontgen EKG USG
Laboratorium PA Nuklir CT Scan/MSCT
Therapi yang sudah diberikan : .........................................................................................................................................
...............................................................................................................................................................................................
Kondisi Pasien Sebelum di Transfer Kondisi Pasien Saat di Transfer

*) coret yang tidak perlu

Beri tanda (√) sesuai yang dipilih

Atas bantuannya kami ucapkan terima kasih

Garut, ...........................................................
Dokter yang mengirim Yang mendampingi Dokter/perawat yang menerima
Dokter/perawat*)

( ........................................) ( .....................................) ( ....................................)

Tanda tangan dan Nama jelas Tanda tangan dan Nama jelas Tanda tangan dan Nama Jelas

RM 12