RSUD TELUK KERAMAT Nama pasien : (L/P)*

Jl.Puringan No78 Kec.Teluk Keramat Tanggal lahir :

Kode 79465 No. RM :

ASESMEN IGD NEONATUS Rm IGD 03.(halaman 1 dari 2)

ASESMEN TRIASE ATS (diisi petugas triase)
Tanggal : Jam datang/triase Jam triase ulang (jika ada):
Kategorri ats inisial: Alsan kategorei (tuliskan ABCD Perubahan ATS : Alasan
I II III IV V yang bermasalah atau tulis indikator I II III I V V kategori:
Potensi risiko infeksi air borne sesuai ATS) DOA-BID Potensi infeksi air
borne

Ruang Resutasi Ruang : Resutasi

Tindakan non bedah Tindakan non bedah
Tindakan bedah Tindakan bedah
R.tunggu IRJ R.Tunggu IRJ
Lanjutkan tujuan hanya Lanjukan tujuan hanya
pemeriksaan penunjang pemeriksaan penunjang
Penanganan awal bagian triase
Nama & (jika ada): Nama &
Paraf Paraf
Petugas Petugas
ASESMEN MEDIS IGD (diisi oleh dokter)
Asesmen medis/ Dokter jam : WIB
Data diperoleh dari pasien keluarga, nama hubungan dengan pasien
KELUHAN UTAMA :.............................................................................................
RIWAYAT PENYAKIT RIWAYAT PENYAKIT DAHULU
SEKARANG :................................................................ (termasuk opname&bedah)
Auto anamnese
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RIWAYAT PENYAKIT
KELUARGA(termasuk penyakit
keturunan&menular)

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Allo Anamnese .........................................................................................................
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Riwayat Pengobatan & Tindakan Prehospital......................................................
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Riwayat alergi obat&makanan ..............................................................................
Evalusi Gawat Napas Skor Down Pada Neonatus
0 1 2
PEMERIKSAAN FISIK
Kesadaran RR : SpO2 : BB : RR x/mnt <60 60-80 >80
Retraksi tidak ada ringan berat
Nadi : Suhu :
................................................................................................................... Sianosis tidak ada hilang dengan menetap dengan o2
o2
................................................................................................................... Air Entry baik penurunan tak ada udara masuk
................................................................................................................... ringan
................................................................................................................... Merintih tidak terdengar dgn terdengar tanpa alat
................................................................................................................... merintih stetoskop
................................................................................................................... interprestasi <4 Tidak ada gawat napas
4-7 Gawat napas
................................................................................................................... >7 Ancaman gagal napas
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PROGRAM HASIL PEMERIKSAAN PENUNJANG
Jam Pemeriksaan Jam Jam Keterangan hasil bernilai penting& ketrangan alasan jika ada delay sampling
order hasil

DIAGNOSA : ...........................................................................................................................................................................................
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RENCANA PELAYANAN/ INTRUKSI TERAPI .....................................................................................................
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EVALUASI (SOAP ....................................................................................................

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TINDAK LANJUT Kebutuhan Edukasi Relevan (Pastikan Lembar Edukasi IGD

I. Observasi di IGD : : Tidak : Ya 1) Pemantauan :……... dan dokumen terkait terisi)
II. Keputusan Rawat Inap 2) Jam … 1.) Edukasi alas an penahanan pasien untuk observasi
Resume Skrining Kebutuhan rawat inap dokumentasi pemantauan di CPPT (RM IGD 03)
(Preventif,Kuratif,Paliatif,Rehabilatuf diPrioritaskan) : 2.) Edukasi rencana asuhan & hasil asuhan yang di harapkan
- Kebutuhan rawat prioritas : 3.) Informed Consent Tindakan operasi & anestesi (LRM
- Kebutuhan Lainnya : 01.1)
- Ruang Inap : Ruang biasa ICU Isolasi …….. 4.) Informed Consent rujukan (LRM 01.6)
- Perawatan prioritas di bidang …………. 5.) Edukasi pengobatan pulang / rawat jalan
DPJP…………… 6.) Edukasi risiko asuhan medis tidak lengkap. Isi LRM 01.2
Alasan : Sesuai Jadwal DPJP Sesuai rujukan Penolakan rawat inap / pengobatan.
DPJP Opname < 30 hari 7.) Edukasi isi Surat Keterangan Kematian
Permintaan Pasien (jika memenuhi ketentuan) Edukasi Penundaan pelayanan, alas an dan alternatif (jika
Saran / Instruksi inap DPJP terjadi)
……………
Keputusan Operasi 3) jam …. Rencana operasi jam ……
Keputusan rujuk 4) jam …… Ke……….
Alasan : APS Ruang rawat Penuh
Perlu alat / ahli
Keputusan Pulang RJ 5) jam …….
Keputusan Pulang APS 6) jam ……..
Kamar Jenazah 7) (DOA / DOR) meninggal jam …..
Keputusan Perawatan d lanjutkan di IGD 8) jam ……
Alasan : menolak dirujuk, sedang ruangan inap penuh
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KELUAR DARI IGD

Keluar dari IGD secara fisik pada tanggal………. Jam…… Dokter Jaga
Ringkasan kondisi saat keluar : Keluhan & Vital Sign
Cara Keluar : Rawat Inap Kamar Operasi Kamar Jenazah
Melarikan diri Pulang atas persetujuan dokter
Pasien di rujuk ke RS lain Pulang APS (………………………)