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KARTU LUKA

PMI Kab : .....................................................................


Identitas Korban
a. Nama : .....................................................................
b. Umur : .....................................................................
c. Jenis Kelamin : L/P
Kesan Umum : .....................................................................
Penilaian diri
Awas
Respon Suara
Korban Nyeri
Tidak Respon
Napas : Kuat/ Lemah/ Tidak ada (Frekuensi : .................. x /menit)
Nadi : Kuat/ Lemah/ Tidak ada (Frekuensi : .................. x /menit)
Tekanan darah : ................................mmHg
Suhu : ................................0C
Jenis Cedera:
a. ........................................................................................
b. ........................................................................................
c. ........................................................................................
d. ........................................................................................
RIWAYAT PENDERITA
a. Keluhan : .....................................................................
b. Obat : .....................................................................
c. Makanan/Minuman : .............................................
d. Penyakit : .....................................................................
e. Alergi : .....................................................................
f. Kejadian : .....................................................................

TANDA VITAL
Jam Napas Nadi Tekanan Suhu (oC) Kulit Ket.
(x/menit) (x/menit) darah
(mmHg)

PENJELASAN TINDAKAN

Serang, ..............................
Penolong

...............................

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