PEMERINTAH KABUPATEN SIDOARJO

DINAS KESEHATAN
PSC (PUBLIC SAFETY CENTER) 119

Nama Pasien : ............................. No. RM : ...........

Umur : ....................... Jenis Kelamin : L/P
Tanggal pengangkutan : ....................... Jam : ..............
Alamat pasien : .....................................................................
CATATAN AMBULAN DAN EVALUASI
A. PERSIAPAN, PEMBERANGKATAN DAN MENUJU LOKASI
NO. Telp yang emnghubungi : ...................................... Lokasi Kejadian :
Tanggal Permintaan : ....................................Jam......... ..............................................................
Nama Penelpon : .................................................... .............................................................
Alasan Pemanggilan : .................................................... Tanggal berangkat : ..................Jam.....
Petugas Evakuasi : o Cek kebenaran telpon dengan meghubungi kembali
o Cek kebenaran lokasi
1. ...................... 3. ....................
2. ......................
B. DI LOKASI
Jam Tiba dilokasi :
Keluhan utama :
Kesadaran :
GCS : E :........ V: ...... M:.......
TRIAGE
Merah Kuning Hijau Hitam

SURVEY PRIMER
Airway Breathing Circulation Exposure
o Paten o Spontan oNadi tidak teraba o Luka terbuka
o Obstruksi total o Tachypnoe oNadi teraba lemah o Benda asing yang tertancap
o Obstruksi parsial o Kusmaul oNadi teraba kuat o Hipotermia
o Bradypnoe o Heat stroke
o Apnoe o Fraktur, hematoma

DAFTAR MASALAH / KONDISI KHUSUS :

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INTERVENSI JAM :
Airway Breathing Circulation Exposure Peralatan
o Oropharyngeal tube o Nasalcanule......lpm IVFD ( Jenis Cairan) o Bebat tekan o Monitor infus
o Endo Tracheal tube o Simplemask ........lpm 1............Tpm/.........cc o Bidai o Pump syringe
o Nasopharyngeal tube o NonRebreathing 2............Tpm/.........cc o Immobilisasi o Pump
o Lain-lain mask ....lpm 3............Tpm/.........cc penuh o Lain-lain :
o Rebreathing.......lpm Folly catheter NO.... o Cegah hipotermi
o Venturi mask ......lpm NGT No.... o Cervical collar
o Lain-lain ........ o Lain-lain

Saksi di lokasi kejadian Status saksi Tanda Tangan

1. ............................ 1. ...................... 1. ..................
2. ............................ 2. ...................... 2. ..................