REKAM MEDIS PASIEN UGD

NO RM :
NAMA :
UMUR :
ALAMAT :
PUSKESMAS KUNIR JENIS KELAMIN : Laki-laki Perempuan
DINAS KESEHATAN KABUPATEN PEMBAYARAN : Umum BPJS ASKES
LUMAJANG KIS/Jamkesmas
Tanggal : Riwayat Alergi Triase :
Jam : WIB

ANAMNESA
KU.......................................................................................................................................................................................
RPS......................................................................................................................................................................................
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RPD...................................................................................................................................................................................
PENILAIAN PRIMER
PENGKAJIAN MERAH KUNING HIJAU
Jalan Napas Obstruksi/Obstruksi Paten Paten
Parsial/stridor
Pernapasan Distress Napas Berat/Hent Distress Napas ringan- Normal
napas,RR > 30 sedang,RR 26-30
Sirkulasi Gangguan hemodinamik Gangguan hemodinamik Stabil
berat/perdarahan tidak ringan, HR:111-130
terkontrol,HR>130 BPsys :80-89,CRT≤2 dtk
BPsys < 80,CRT > 2 dtk
Kesadaran (GCS) GCS ≤8 GCS :9-14 GCS :15
Nyeri Sedang-berat Tidak nyeri-ringan
Kondisi Mental Tidak Kooperatif Kooperatif
PEMERIKSAAN FISIK DIAGNOSA MEDIS:
Keadaan Umum Baik Sedang Buruk
Tanda-Tanda Vital TD.........mmHg Nadi........x/mnt Suhu....... oC
RR.......x/mnt BB ……..Kg
Kepala.....................................................................................................
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TERAPI
Leher.......................................................................................................
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Thorax.....................................................................................................
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Abdomen................................................................................................
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Genetalia................................................................................................
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Extremitas..............................................................................................
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PEMERIKSAAN PENUNJANG
Laborat : Hasil Ada/belum PETUGAS/DOKTER
DL GDA LFT RFT WIDAL UL
RADIOLOGI : Hasil Ada/belum
EKG : Hasil Ada/belum

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