PT.

NURMA HUSADA ABADI

RUMAH SAKIT PUNTEN
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NO. RM : ......................................................
TRIAGE PASIEN
NAMA PASIEN : ............................................... L/P
No. BED : TANGGAL LAHIR : ........................................................

Tanggal Masuk : Jam Masuk : Jam Periksa :

Jenis Kasus :  Trauma  Non-Trauma  Obstetri Diantar Polisi :  Ya  Tidak
Cara Datang :
 Kendaraan Pribadi  Ambulans  Tidak  Ya Tgl/Jam :
 Kendaraan Umum  Ambulans 119 Rujukan dari :
Tgl & Jam Kejadian : Tempat Kejadian :
Keluhan Utama :

NON FALSE
PEMERIKSAAN RESUSITASI EMERGENCY Tanda vital URGENT
URGENT EMERGENCY
 Sumbatan  Bebas Tekanan Darah :  Bebas
JALAN NAFAS ................ mmHg
 Bebas  Bebas
 Henti Nafas  RR >32x/mnt  RR 24-
SaO2 :
 RR < 1x/mnt  Wheezing 32x/mnt
........................%
 Sianosis  Wheezing
 Apnea/  Neonatus  Neonatus
Megap-megap >80x/mnt atau <60x/mnt
PERNAFASAN  Neonatus <40x/mnt  Sianosis  Normal  Normal
<60x/mnt  Sianosis Frekuensi Napas: sentral
 Sianosis sentral ................ x/mnt menetap
sentral menetap dengan O2
menetap dengan O2
dengan O2
 Henti  Nadi teraba  Nadi 120 – 150
Jantung Lemah x/mnt
 Nadi tidak  Bradikardia
teraba/lemah (<50x/mnt)
 Takikardia
(>150x/mnt)
 Frek Nadi  Frek Nadi  Frek Nadi
Frekuensi Nadi:
SIRKULASI Neonatus Neonatus
................ x/mnt
Neonatus  Normal  Normal
<60x/mnt <100x/mnt >160x/mnt
 Pucat (Pale)  Pucat (Pale)  TD Sist >160
 Akral Dingin  Akral Dingin mmHg
 CRT <2 detik  TD Sist >100
mmHg
 Neonatus  Neonatus  Neonatus
CRT >3detik CRT >3detik CRT <3detik
 GCS < 9  GCS 9-12 GCS  GCS > 13  GCS 15  GCS 15
E: V: M:  Luka dengan  Luka Ringan
Resiko tanpa Resiko
Infeksi Infeksi
KESADARAN  Trauma dgn
Fracture
 Neonatus  Neonatus <36,50C Suhu : ............ 0C  >37,50C -  >36,50C -  >36,50C -
<36,50C <36,50C <37,50C <37,50C
AREA P1 P2 P3
RESPON TIME 1 menit 10 menit 60 menit
Nilai
0 (Tidak Nyeri)
 1 – 3 (Ringan)
 4 – 6 (Sedang)
 7 – 10 (Berat)

ALERGI GANGGUAN PERILAKU PETUGAS TRIAGE

 Tidak Ada Alergi  Marah
 Alergi Obat : ............................
................................................  Cemas
 DOA
 Alergi Makanan : .....................
................................................  Panik
(.........................................)
Tanda Tangan & Nama Terang

PT. NURMA HUSADA ABADI

RUMAH SAKIT PUNTEN
www.rspunten.com
 PENGKAJIAN GAWAT NO. RM : ......................................................
NAMA PASIEN : ............................................... L/P
DARURAT TANGGAL LAHIR : ......................................................

Jam Mulai Tindakan

CATATAN TERINTEGRASI (diisi oleh perawat)
BB : ....................... kg Resiko Jatuh :
TB : ....................... cm  Tidak Beresiko  Resiko
Status Gizi :  Kurang  Baik  Lebih Rendah  Resiko Tinggi

Keperawatan
Evaluasi
Masalah Keperawatan Jam Implementasi
Teratasi Sebagian Belum
1. Gangguan Jalan Nafas
2. Tidak efektifnya bersihan jalan
nafas
3. Pola nafas tidak efektif
4. Gangguan Pertukaran Gas
5. Penuruna Curah Jantung
6. Resiko Infeksi/sepsis
7. Intoleransi Aktifitas
8. Perubahan Nutrisi Kurang/lebih
9. Gangguan Integritas
Kulit/Jaringan
10.Retensio/Inkontinensia Urine
11.Resiko Komplikasi Syok
12.Gangguan Perfusi Jaringan Perifer
13.Gangguan Rasa Nyaman
14.Gangguan Volume Cairan
15.Gangguan Perfusi Serebral
16.Gangguan Termoregulasi
17.Lain-lain :
 .............................................
 .............................................
 .............................................
 .............................................
 .............................................

Perawat / Bidan

( ................................. )
Tanda Tangan & Nama Terang

PT. NURMA HUSADA ABADI

RUMAH SAKIT PUNTEN
www.rspunten.com

PENGKAJIAN GAWAT NO. RM : ......................................................

NAMA PASIEN : ............................................... L/P
DARURAT TANGGAL
LAHIR : ......................................................
Pengkajian Medis :  P1  P2  P3
Situation :  Auto-anamnesis  Alo-anamnesis (Jam : ___________ WIB)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________
Background : ((Jam : ___________ WIB)
Primary Survey : A : ........................................ B : ........................................ C : .......................................
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Jam Dikirim Pemeriksaan Penunjang : Jam Diterima
Laboratorium :
EKG :
Radiologi :
Assesmen Awal :
Jam Recommendation : Penatalaksanaan/Pengobatan/Rencana Tindakan

Konsultasi
WIB WIB
WIB WIB
Diagnosis :

Disposisi :
Perawatan Lanjutan :  Rawat Jalan  Rawat Inap  Pulang Paksa  Dirujuk/Alihrawat  Meninggal
Bila Rawat Jalan/Pulang paksa, Tanggal : Jam : Vital Sign sebelum
Bila Rawat Inap, Transfer ke Ruang : transfer/rujuk/pulang :
Bila Meninggal, Tanggal : Jam : Tek darah :
Causa : Nadi :
Bila dirujuk/alih rawat, Tanggal : Jam : RR :
Suhu :
GCS :
Dokter

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PT. NURMA HUSADA ABADI

RUMAH SAKIT PUNTEN
www.rspunten.com

RESUME RAWAT JALAN NO. RM : ......................................................

NAMA PASIEN : ............................................... L/P
IGD TANGGAL LAHIR : ......................................................

Tanggal Masuk : Tanggal Keluar :

Diisi oleh dokter yang merawat :
Anamnesis .........................................................................................................................
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Pemeriksaan Fisik .........................................................................................................................
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Pemeriksaan Penunjang .........................................................................................................................
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Diagnosa .........................................................................................................................
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Tindakan yang dilakukan .........................................................................................................................
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Obat yang diberikan .........................................................................................................................
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Kondisi pada saat pulang .........................................................................................................................
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Anjuran/Rencana/Kontrol  RS. Punten, Poli ....................................  Puskesmas
selanjutnya  Lain-lain, .........................................
Alasan Pulang  Dapat berobat jalan
 Pulang Atas Permintaan
 Sembuh
 Meninggal
 Pindah RS Lain : ...........................
Batu, tgl ........................... Jam ............
Dokter yang merawat

( ................................. )
Tanda Tangan & Nama Terang