KARTU LUKA

PALANG MERAH INDONESIA

BIODATA PENILAIAN DINI

Nama Korban : ........................................ L/P Kesan Umum : Trauma / Medis

Alamat : .............................................. Respon : Awas/Suara/Nyeri/Tidak Respon
Nafas : Ada / Tidak Ada
Nama Saksi : ........................................ L/P Nadi : Ada / Tidak Ada
Alamat : .............................................. Perdarahan : Ada / Tidak Ada
Phone : ..............................................
PEMERIKSAAN FISIK
JENIS LUKA
1. ..................................................................................................................
2. ..................................................................................................................
3. ..................................................................................................................
TINDAKAN PERTOLONGAN YANG DILAKUKAN
1. ..................................................................................................................
2. ..................................................................................................................
3. ..................................................................................................................

TANDA VITAL
1. Frekuensi nafas : .............../menit
2. Frekuensi nadi : ............../menit
3. Suhu Relatif : ...............
4. Kondisi Kulit : Lembab/ Kering/ Pucat/ Normal/ Kebiruan/ Berkeringat
KOMPAK

1. Keluhan : .............................................
2. Obat yang terakhir diminum : .............................................
3. Makanan & minuman yang terakhir diknsumsi : .............................................
4. Penyakit yang diderita : ..............................................
5. Alergi yang diderita : ..............................................
6. Kejadian : ..............................................
PEMERIKSAAN BERKALA

1. Frekuensi nafas : .............../menit

2. Frekuensi nadi : ............../menit
3. Suhu Relatif : ...............
4. Kondisi Kulit : Lembab/ Kering/ Pucat/ Normal/ Kebiruan/ Berkeringat

KETERANGAN
Rujuk ke : Rumah sakit/ Puskesmas/ Dokter/ Lainya Blitar, ..............................
Transportasi : Ambulance/ Becak/ Lainya Penolong
Inventaris Korban : ...........................................................................
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