Nama :

Tgl. Lahir :
No. RM : Jenis Kelamin : L/P
Alamat :
No. Hp :
TRIAGE EMERGENCY ROOM
Stiker Alergi Riwayat Alergi Petunjuk pengisian :
(Jika ada) □ Tidak □ Ya .......................................................................................................................................................................................................................................................................................................................... *Beri tanda centang sesuai dengan
pilihan
................................................................................................................................................................................................................................................................................................................................................... ** Coretlah yang tidak perlu
................................................................................................................................................................................................................................................................................................................................................... *** Arsir sesuai dengan lokasi yang dipilih

PEMERIKSAAN LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

RESUCITATION EMERGENCY URGENT SEMI URGENT FALSE EMERGENCY
SKALA TRIAGE (Segera) (10 menit) (30 menit) (60 Menit) (120 Menit)
GCS < 9 GCS 9 – 12 GCS 13 - 14 GCS 15 GCS 15
Kejang Gelisah Apatis
KESADARAN
Tidak ada respon Hemiparesis Delirium
Nyeri dada Somnolen
Henti Jantung Nadi teraba lemah Nadi kuat Nadi kuat Nadi kuat
Nadi tidak teraba < 3m HR > 180 T > 380C Akral hangat Frekuensi nadi normal Frekuensi nadi normal
Akral dingin 3m – 3y HR > 160 T > 390C Takikardi 100 - 140
Sianosis 3 – 8y HR > 140 GDS > 288 mg/dl
SIRKULASI BP < 80 mmhg (systolic) dewasa > 8y HR > 100 < 50
SpO2 < 92%
CRT > 2 sec
Keringat dingin
GDS < 54 mg/dl
Sumbatan total Bebas Bebas Bebas Bebas
JALAN NAPAS
Sumbatan partial
Henti napas 3m RR > 50 Normal Normal Normal
Bradipnoe RR < 10 x/mnt 3m – 3y RR > 40 Retraksi ringan
PERNAPASAN Retraksi berat 3 – 8y RR > 30
> 8y RR > 20
Retraksi sedang
RASA NYERI 7 – 10 (nyeri hebat) 4 – 6 (nyeri sedang) 1 -3 (nyeri ringan) 0 (tidak nyeri)
SUMBER DAYA > 1 > 1 > 1 1 Tidak ada
Waktu Dilakukan Triage
KATEGORI TRIAGE**) : LEVEL 1 / LEVEL 2 / LEVEL 3 / LEVEL 4 / LEVEL 5 Nama Dokter/Perawat Tanda Tangan
Triage berdasarkan Australasian Triage Scale dan Emergency Severity Index
Tanggal Jam wita