DETASEMEN KESEHATAN WILAYAH MALANG

RUMAH SAKIT TINGKAT III BALADHIKA HUSADA

FORMULIR SKRINING PASIEN DARI LUAR RUMAH SAKIT

Nama Pasien :............................................. Asal Rujukan :...............................................

Jenis Kelamin :............................................. Alasan Dirujuk :..............................................
Tanggal&Jam :.............................................
Diagnosa :.............................................

I. PEMERIKSAAN FISIK
Keadaan Umum : ...........................................................................................................
Kesadaran : ...........................................................................................................
Pemeriksaan Tanda-tanda vital :
Tensi : ..... mmHg, Suhu : ..... °C, Nadi : ..... x/mnt, Pernafasan : ..... x/mnt SpO2:....%
Riwayat Penyakit : ...........................................................................................................
Riwayat Alergi : ...........................................................................................................

II. PEMERIKSAAN DIAGNOSTIK YANG DISERAHKAN

Laboratorium : ..........................................................................................................
EKG Foto Abomen CT Scan
Toraks Foto Spirometri Endoscopi
Foto Cervical / Vetebrata Echo/Treadmill
Foto Genu/Femur USG/MRI/A
Lain : .........................................................................................................................

III. TINDAKAN MEDIS YANG SUDAH DILAKUKAN

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

IV. THERAPI
Infus : ....................................................................................................................................
Obat Injeksi : ....................................................................................................................................
1. .................................................................... 4. ....................................................................
2. .................................................................... 5. ....................................................................
3. .................................................................... 6. ....................................................................
Obat Oral :
1. .................................................................... 4. ....................................................................
2. .................................................................... 5. ....................................................................
3. .................................................................... 6. ....................................................................

Intake Oral Terakhir :.....................................

Riwayat Vaksin :
Keterangan : Terima Tolak

Jam : Jam :
Perawat yang menyerahkan Perawat yang menerima
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