PANITIA PELAKSANA

PORPROV JAWA BARAT XIV CABANG OLAHRAGA P E N T A Q U E

FORMULIR TINDAKAN &RUJUKAN

(Treatment & Hand Over Sheet)
Tanda Vital
Nama Petugas (Officer In Charges) :……………………………….. Tanda Tangan (Sign) : …………… Jam Nafas Nadi TD Kulit Ket
Nama Sopir (Driver In Charges) :……………………………….. Tanda Tangan (Sign) : ……………

Identitas Pasien (Patience Identity) :

a. Nama (Name) :……………………………….. L (Male) /P (Female)
b. Umur (Age) :……….…..…tahun (Year (s) old)
c. Nomor Punggung (Back Number) :………………………………..
d. Kontingen (Contingent) :………………………………..
Tanda Vital
Informasi Masuk (Received Information At) Jam (Hours) …………………………….....WIB Jam Nafas Nadi BP Kulit Ket
Waktu Kejadian (Time of Accident) Jam (Hours) …………………………….....WIB Rujukan (send to) …………………………………………….
Tiba dilokasi (Reach Scene at) Jam (Hours) …………………………….....WIB (Rumah Sakit(Hospital) /Puskesmas(district Health Centre) /Poliklinik(Clinic) )
Jenis Kejadian (Kind Of Action/accident) :
Keadaan Pasien (Patience condition) : Gambar/Anatomi

Penilaian Dini (Inisial Assessment) :

a. Nafas (Airway & Breathing)
b. Nadi (Pulse/Circulation)
c. Suhu (Body Temperatur)
e. Saturasi Oksigen (Oxigen saturation / SPO 2 )
e. Tekanan Darah (Blood Preasure)
: Kuat (Strong) /Lemah(weak) /Tidak Ada(Unidentified ) (Frekwensi…………X/menit)
: Kuat (Strong) /Lemah(weak) /Tidak Ada(Unidentified ) (Frekwensi………....X/menit)
: Dingin(Cold) /Lembab berkeringat(Clammy)
: Panas(Hot) /Kering(Dry) Normal ………………… oC
: %
: mmHg

Riwayat Pasien(Patience History) (Anamnesa):

a. Keluhan (Complaint) : …………………………………………………………….
b. Obat (Drugs) : …………………………………………………………….
c. Makanan/Minuman (foot & Drinks) : …………………………………………………………….
d. Penyakit (Disease) : …………………………………………………………….
e. Alergi (Alergy) : …………………………………………………………….
f. Kejadian (Accident) : …………………………………………………………….
………………….,…………………………
Penjelasan Tindakan (Treatment Detail)
Yang menyerahkan Yang menerima,
Petugas Ambulance, Petugas,
(Ambulance Officer In Charges) (Hospital Officer In Charges)