Lampiran : 6 26

FORMAT PENDELEGASIAN PASIEN

1.BIO DATA :

Nama Pasien : .......................... No.RM :....................

Umur : Tahun Ruang :.....................

Tanggal Masuk :..................... Diagnosa Medik : .........................

2.Masalah yang ditemukan :

a) ....................................................................................................................................
b). ...................................................................................................................................
c)......................................................................................................................................
d)....................................................................................................................................

3. Masalah yang sudah dilaksanakan :

a).................................................................................................................................
b). .................................................................................................................................
c)...................................................................................................................................
d).................................................................................................................................

4. Masalah yang sudah teratasi :

a). ...................................................................................................................................
b)...................................................................................................................................
c).....................................................................................................................................
d)....................................................................................................................................

5. Masalah yang belum teratasi :

a). ..................................................................................................................................
b)...................................................................................................................................
c)...................................................................................................................................
d)..................................................................................................................................

6. Kondisi pasien saat dioperkan :

a). Status kesadaran :.................................................................................................
b) Status Respirasi : .................................................................................................
c).Status Sirkulasi : .................................................................................................
d). Status nutrisi dan cairan : .....................................................................................
e). Status Perkemihan : ..............................................................................................

7. Rencana Selanjutnya :
a)...................................................................................................................................
b)..................................................................................................................................
c).................................................................................................................................
d)..................................................................................................................................
Nama Perawat Semarang , ............................2019
Yang menerima delegasi Mahasiswa yang mendelegasikan

(..........................................................) ( ....................................................)
Nim : ..........................................