RUMAH SAKIT NAHDLATUL ULAMA JOMBANG

Jl. KH. Hasyim Asy’ari No. 211 Jombang 61471 RM. UGD. 01
Telp. (0321) 878-700, Fax. (0321) 877-700
Email : rsnujombang@yahoo.co.id
NO. RM

Nama :
Tgl. Lahir : L/P
LEMBAR TRIAGE Alamat :
Kelas : III / II / I / VIP / VVIP
Mohon diisi atau ditempel stiker jika ada

No. BED

Masuk Tanggal : Jam : Selesai Jam :

Trauma Non Trauma Obstetri Kasus Polisi Ya Tidak
Cara Datang Transportasi ke UGD Komunikasi Sebelumnya
Datang sendiri Tidak Ya Jam :
Rujukan Rujukan dari
Tanggal & jam kejadian Tempat kejadian
Keluhan Utama
Riwayat Penyakit Sekarang

Riwayat Penyakit Terdahulu

Riwayat Penggunaan Obat

Pemeriksaan Tanda Vital P1 P2 P3

Sumbatan/ Jalan Nafas Bebas Bebas Bebas
Ancaman
Henti Nafas Freq. Nafas : x/mnt Bradipnea (<8) RR (8-12) RR (12-24)
PERNAFASAN
Gasping Takipnea (>30) RR (25-30)

Sianosis SaO2 % SaO2 < 92% SaO2 92% - 95% SaO2 >95%
Henti Jantung Freq. Nadi : x/mnt Bradicardis (<60) Nadi Kuat Nadi Kuat

Nadi tidak Takicardis (>120) Nadi Nadi

terasa/lemah Tensi Darah : mmHg (>100) (60-100)
SIRKULASI
Hipotensi (TDS <90 TDS (140-180) TDS (100-140)
Akral Dingin Suhu : C atau MAP < 80) atau (90-100)
Hipertensi (TDS <90 MAP (>100) MAP (80-100)
CTR >2 detik atau MAP < 80) atau (<80)
Kejang Riwayat Alergi GCS < 13 GCS (13-14) GCS (15)
Un_respon Tidak Ada

Respon nyeri Obat

KESADARAN Resiko
Respon verbal Pemburukan cepat
Makanan
Respon Time 0 menit 10 menit 60 menit
Gangguan Perilaku Perawat Dokter TRIAGE
Ya
DOA
Tidak

( Tanda tangan & Nama Terang ) ( Tanda tangan & Nama Terang )
 RUMAH SAKIT NAHDLATUL ULAMA JOMBANG
Jl. KH. Hasyim Asy’ari No. 211 Jombang 61471 RM. UGD. 02
Telp. (0321) 878-700, Fax. (0321) 877-700
Email : rsnujombang@yahoo.co.id
NO. RM

Nama :
Tgl. Lahir : L/P
PENGKAJIAN GAWAT DARURAT Alamat :
Kelas : III / II / I / VIP / VVIP
Mohon diisi atau ditempel stiker jika ada

No. BED

Masuk Tanggal : Jam :

CATATAN TERINTEGRASI ( Diisi Perawat )

Berat Badan Tinggi Badan Resiko Jatuh
Tidak Berisiko
Status Gizi Kurang Baik Lebih Resiko Rendah
Nyeri Ya Tidak Resiko Tinggi
Untuk Umur < 9 th Untuk Umur > 9 th Nilai Nyeri

0 Tidak Nyeri
1-3 Nyeri Ringan
4-6 Nyeri Sedang
7-9 Nyeri Berat Terkontrol
10 Nyeri Berat Tidak Terkontrol
................................................................................................................
...............................................................................................................
................................................................................................................
............................................................................................................... .......................................................................................................................
........................................................................................................................
.......................................................................................................................
........................................................................................................................
................................................................................................................
...............................................................................................................
................................................................................................................
............................................................................................................... .......................................................................................................................
........................................................................................................................
.......................................................................................................................
........................................................................................................................
................................................................................................................
KEPERAWATAN
...............................................................................................................
................................................................................................................
............................................................................................................... .......................................................................................................................
........................................................................................................................
.......................................................................................................................
........................................................................................................................
................................................................................................................ .......................................................................................................................
.......................................................................................................................................................................................................................................
Masalah Keperawatan Implementasi Evaluasi
1 Bersihkan jalan nafas tidak efektif
2 Pola Nafas tidak efektif
3 Nyeri
4 Hipertermia / Hipotermia
5 Kerusakan pertukaran Gas
6 Kelebihan/kekurangan volume cairan
7 Penurunan Curah jantung
8 Gangguan Integritas Kulit / Jaringan
9 Intoleransi Aktifitas
Perubahan Perfusi jaringan jantung /
10
Paru / Jaringan Otak / Perifer
11 Perdarahan
12 Gangguan Eliminasi Uri / Alvi
13 Lain - lain

Perawat / Bidan

( Tanda tangan & Nama Terang )

 RUMAH SAKIT NAHDLATUL ULAMA JOMBANG
Jl. KH. Hasyim Asy’ari No. 211 Jombang 61471 RM. UGD. 03
Telp. (0321) 878-700, Fax. (0321) 877-700
Email : rsnujombang@yahoo.co.id
NO. RM

Nama :
Tgl. Lahir : L/P
STATUS LOKALIS Alamat :
Kelas : III / II / I / VIP / VVIP
Mohon diisi atau ditempel stiker jika ada

Kanan Kiri Kiri Kanan

Kanan Kiri Kiri Kanan

Kiri Palmar (anterior) Kanan

Kanan Kiri Kiri Kanan

Plantar (Pasterior) Dorsal (Anterior) Kiri Dorsal (posterior) Kanan

Kanan Kiri Kiri Kanan

Kronologi:
 RUMAH SAKIT NAHDLATUL ULAMA JOMBANG
Jl KH HasyimAsy’ari No 211 Jombang 61471 RM UGD 04
Telp (0321) 878-700 Fax (0321) 877-700
Email : rsnujombang@yahoo co id
NO RM

Nama :
Tgl Lahir : L/P
PENGKAJIAN MEDIS Alamat :
Kelas : III / II / I / VIP / VVIP
Mohon d a au d empe ke ka ada
...........................
..........................
...........................
.......................... ...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...........................
..........................
...........................
.......................... ...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...........................
Anamnesis
..........................
...........................
.......................... Auto anamnesis Alo anamnesis
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
........................... ...................................................................................................................................
.............................................................................................................................................................

............................................................................................................
.............................................................................................................
............................................................................................................
.....................................................................................................................................................................................................................................
.......................................................................................................................
........................................................................................................................
.......................................................................................................................
............................................................................................................
.............................................................................................................
............................................................................................................
.....................................................................................................................................................................................................................................
.......................................................................................................................
........................................................................................................................
.......................................................................................................................
............................................................................................................
.............................................................................................................
Pemeriksaan Fisik
............................................................................................................
.....................................................................................................................................................................................................................................
.......................................................................................................................
........................................................................................................................
.......................................................................................................................
............................................................................................................
.....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
.......................................................................................................................
Kepala
Leher
Dada
Perut
Extrimitas
.............................................................................................................
............................................................................................................
.............................................................................................................
............................................................................................................ .......................................................................................................................
........................................................................................................................
.......................................................................................................................
........................................................................................................................
.............................................................................................................
............................................................................................................
.............................................................................................................
............................................................................................................ .......................................................................................................................
........................................................................................................................
.......................................................................................................................
........................................................................................................................
Pemeriksaan Penunjang
.............................................................................................................
............................................................................................................
............................................................................................................. .......................................................................................................................
........................................................................................................................
.......................................................................................................................
....................................................................................................................................................................................................................................
........................................................................................................................
.............................................................................................................
............................................................................................................ .......................................................................................................................
Laboratorium
EKG
Radiologi
...............................
..............................
...............................
.............................. ...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...............................
..............................
...............................
.............................. ...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Diagnosis
...............................
..............................
...............................
.............................. Kerja :
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...............................
.............................. ...................................................................................................................................
...................................................................................................................................
.............................................................................................................
............................................................................................................ .......................................................................................................................
........................................................................................................................
.............................................................................................................
............................................................................................................
.............................................................................................................
............................................................................................................ .......................................................................................................................
........................................................................................................................
.......................................................................................................................
........................................................................................................................
.............................................................................................................
............................................................................................................
Planning : Penata laksanaan / Pengobatan / Rencana
.............................................................................................................
............................................................................................................ .......................................................................................................................
........................................................................................................................
Tindakan / Konsultasi
.......................................................................................................................
........................................................................................................................
.............................................................................................................
.............................................................................................................
............................................................................................................ .......................................................................................................................
....................................................................................................................................................................................................................................
........................................................................................................................
.......................................................................................................................

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

Tgl Jam
............................................................................................................
.............................................................................................................
............................................................................................................
.....................................................................................................................................................................................................................................
.......................................................................................................................
........................................................................................................................
.......................................................................................................................
............................................................................................................
....................................................................................................................................................................................................................................
.............................................................................................................
............................................................................................................. .......................................................................................................................
........................................................................................................................
.............................................................................................................
............................................................................................................
............................................................................................................. .......................................................................................................................
........................................................................................................................
.......................................................................................................................
....................................................................................................................................................................................................................................
........................................................................................................................
.............................................................................................................
............................................................................................................
...............................................
............................................................................................................. .......................................................................................................................
.......................................................................................................................

Dokter Jaga UGD

( Tanda tangan & Nama Terang )

 RUMAH SAKIT NAHDLATUL ULAMA JOMBANG
Jl. KH. Hasyim Asy’ari No. 211 Jombang 61471 RM. UGD. 05
Telp. (0321) 878-700, Fax. (0321) 877-700
Email : rsnujombang@yahoo.co.id
NO. RM

Nama :
PEMBERIAN INFORMASI Tgl. Lahir : L/P
Alamat :
TINDAKAN KEDOKTERAN Kelas : III / II / I / VIP / VVIP
Mohon diisi atau ditempel stiker jika ada

No. BED

Tanggal : Jam :

TINDAKAN KEDOKTERAN

Dokter Pelaksana

Pemberi Informasi
Penerima Informasi /
Pemberi Persetujuan *)

No. JENIS INFORMASI ISI INFORMASI TANDA TANGAN

1 Diagnoisis (WD dan DD)

2 Dasar DIAGNOSIS

3 Tindakan KEDOKTERAN

4 Indikasi Tindakan

5 Tata Cara

6 Tujuan

7 Resiko

8 Komplikasi

9 Prognosis

10 Alternatif

Dengan ini menyatakan bahwa saya Dokter ....................................

Telah menerangkan bahwa hal - hal diatas secara benar dan jelas, dan
memberi kesempatan untuk bertanya dan / atau diskusi

Dengan ini menyatakan bahwa saya / keluarga pasien ..........................*)

Telah menerima informasi sebagaimana diatas, dan telah saya beri tanda /
paraf dikolom kanan nya serta telah diberi kesempatan untuk bertanya
dan / atau diskusi, dan telah memahami nya

*) Bila pasien tidak berkompeten atau tidak mau menerima informasi maka
Informasi diberikan kepada wali / keluarga terdekat
 RUMAH SAKIT NAHDLATUL ULAMA JOMBANG
Jl. KH. Hasyim Asy’ari No. 211 Jombang 61471 RM. UGD. 06
Telp. (0321) 878-700, Fax. (0321) 877-700
Email : rsnujombang@yahoo.co.id
NO. RM

LEMBAR CATATAN PENGOBATAN PASIEN (CPP-5) UGD

Tanggal : Alergi :
Nama Pasien : Tanggal Lahir :
Status : BPJS / UMUM / Lainnya
No Nama Obat / Alkes Satuan Jumlah Permintaan Jumlah Pemberian
1 Ringer Lactat Fls
2 NaCl 0,9% Fls
3 D5% Fls
4 D10% Fls
5 D5 0.225 NS Fls
6 D5 0,45 NS Fls
7 KAEN 3B Fls
8 KAEN 4B Fls
9 Spuit 3cc Pcs
10 Spuit 5cc Pcs
11 Spuit 10cc Pcs
12 Iv cath No. : Pcs
13 Infus set Pcs
14 Transfusi set Pcs
15 Spalk Pcs
16 Foley Cateter No : Pcs
17 Urine bag Pcs
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Dokter Perawat Apoteker / TTK

Keterangan
Rangkap 2 (dua)
Lembar 1 ( Putih ) : RM
Lembar 2 ( Hijau ) : Farmasi
 RUMAH SAKIT NAHDLATUL ULAMA JOMBANG
Jl. KH. Hasyim Asy’ari No. 211 Jombang 61471 RM. UGD. 07
Telp. (0321) 878-700, Fax. (0321) 877-700
Email : rsnujombang@yahoo.co.id
NO. RM

Nama :
PERSETUJUAN Tgl. Lahir : L/P
Alamat :
TINDAKAN KEDOKTERAN Kelas : III / II / I / VIP / VVIP
Mohon diisi atau ditempel stiker jika ada

Saya yang bertanda tangan dibawah ini :

Nama L/P
Umur Tahun
Alamat Rumah

No. KTP / Bukti Diri lain

No. HP
dengan ini menyatakan dengan sesungguhnya telah memberikan

PERSETUJUAN
untuk dilakukan tindakan KEDOKTERAN berupa *)
Terhadap diri saya sendiri / Suami / Istri / Anak / Orang tua saya, yaitu

Nama L/P
Umur Tahun
Alamat Rumah

No. KTP / Bukti Diri lain

Yang dirawat di Ruang : No. Bed :

yang tujuan sifat dan perlunya tindakan KEDOKTERAN tersebut serta resiko yang dapat ditimbulkan,
telah dijelaskan oleh Dokter, dan saya telah mengerti sepenuh nya

Demikian pernyataan persetujuan ini saya buat dengan penuh kesadaran dan tanpa paksaan.

Jombang, ....................................20 ....

Jam : ........................... WIB.

Saksi - Saksi Dokter yang menjelaskan Yang Menyetujui

Perawat

( ........................................ ) ( ........................................ ) ( ........................................ )

Tanda tangan & Nama Perawat Tanda tangan & Nama Dokter Tanda tangan & Nama Jelas

Saksi - saksi
Pihak Pasien
Keluarga Pasien

( ........................................ )
Tanda tangan & Nama Jelas
*) Isi dengan jelas Tindakan yang akan dilakukan
**) Pilih yang benar
 RUMAH SAKIT NAHDLATUL ULAMA JOMBANG
Jl. KH. Hasyim Asy’ari No. 211 Jombang 61471 RM. UGD. 08
Telp. (0321) 878-700, Fax. (0321) 877-700
Email : rsnujombang@yahoo.co.id
NO. RM

Nama :
PENOLAKAN Tgl. Lahir : L/P
Alamat :
TINDAKAN KEDOKTERAN Kelas : III / II / I / VIP / VVIP
Mohon diisi atau ditempel stiker jika ada

Saya yang bertanda tangan dibawah ini :

Nama L/P
Umur Tahun
Alamat Rumah

No. KTP / Bukti Diri lain

No. HP
dengan ini menyatakan dengan sesungguhnya telah memberikan

PENOLAKAN
untuk dilakukan tindakan KEDOKTERAN berupa *)
Terhadap diri saya sendiri / Suami / Istri / Anak / Orang tua saya, yaitu

Nama L/P
Umur Tahun
Alamat Rumah

No. KTP / Bukti Diri lain

Yang dirawat di Ruang : No. Bed :

Saya memahami perlunya dan manfaatnya tindakan KEDOKTERAN tersebut serta resiko yang dapat
ditimbulkan, telah dijelaskan oleh Dokter, dan saya telah mengerti sepenuh nya .....................
Saya juga menyadari bahwa tindakan kedokteran bukanlah tindakan yang pasti, semua tergantung
kepada Ridlo Allah SWT.
Demikian pernyataan ini saya buat dengan penuh kesadaran dan tanpa paksaan dari pihak manapun.
Jombang, ....................................20 ....
Jam : ........................... WIB.

Saksi - Saksi Dokter yang menjelaskan Yang Menolak

Perawat

( ........................................ ) ( ........................................ ) ( ........................................ )

Tanda tangan & Nama Perawat Tanda tangan & Nama Dokter Tanda tangan & Nama Jelas

Saksi - saksi
Pihak Pasien
Keluarga Pasien

( ........................................ )
Tanda tangan & Nama Jelas

*) Isi dengan jelas Tindakan yang akan dilakukan

**) Pilih yang benar
 RUMAH SAKIT NAHDLATUL ULAMA JOMBANG RM. UGD. 09
Jl. KH. Hasyim Asy’ari No. 211 Jombang 61471
Telp. (0321) 878-700, Fax. (0321) 877-700
Email : rsnujombang@yahoo.co.id
NO. RM

Nama :
Tgl. Lahir : L/P
RESUME UGD Alamat
Kelas
:
: III / II /I/ VIP /VVIP
Mohon diisi atau ditempat stiker jika ada

Diisi oleh dokter yang merawat

Tanggal Masuk : Jam Masuk :
1. Anamnesis :

2. Pemeriksaan Fisik :

3. Pemeriksaan Penunjang :

4. Diagnosa :

5. Tindakan yang dilakukan :

6. Obat yang diberikan :

7. Kondisi pada saat pulang :

8. Anjuran / Rencana / Kontrol Selanjutnya ke:

RSNU Jombang, Poli............................. Puskesmas

9. Alasan pulang
Dapat berobat jalan Sembuh
Pulang Atas Permintaan Pindah/Rujuk RS Lain :....................................

Jombang, .................................Jam...........
Dokter yang merawat

( )
Tanda tangan & Nama Terang