RM 8 UPT PKM WTS JAN 2022 / REV 1

NAMA : _______________________L/P
TANGGAL LAHIR : __________________________
ALAMAT : __________________________

TRANSFER PASIEN ANTAR UNIT

Dokter yang merawat : _____________________________________________________________________

Diagnosis Masuk : _____________________________________________________________________
Tanggal / Jam Masuk Unit : _____________________________________________________________________
Dari Unit : _____________________________________________________________________
Tanggal / Jam Pindah Unit : _____________________________________________________________________
Ke Unit : _____________________________________________________________________
Diagnosis Sekarang : _____________________________________________________________________
1.PEMERIKSAAN
a. Keadaan Umum : _____________________________________________________________________
b. Kesadaran : _____________________________________________________________________
c. Tanda - tanda Vital : _____________________________________________________________________
d. Keluhan Masuk : _____________________________________________________________________
e. Indikasi MRS : _____________________________________________________________________
f. Riwayat Penyakit : _____________________________________________________________________
g. Riwayat Alergi : _____________________________________________________________________
h. Alasan Pindah Unit : _____________________________________________________________________
2. PEMERIKSAAN DIAGNOSIS YANG SUDAH DILAKUKAN
Laboratorium : _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
3. PEMBERIAN THERAPI
Infus:
Obat Injeksi:
a. _____________________________________________d. ______________________________________
b. _____________________________________________e. ______________________________________
c. _____________________________________________f. ______________________________________
Obat Oral:
a. _____________________________________________d. ______________________________________
b. _____________________________________________e. ______________________________________
c. _____________________________________________f. ______________________________________
Lainnya : ____________________________________________________________________________
4.TINDAKAN MEDIS YANG SUDAH DILAKUKAN
a. _____________________________________________d. ______________________________________
b. _____________________________________________e. ______________________________________
c. _____________________________________________f. ______________________________________
Diet : _______________________________________________________________________________

Mengetahuai,

Yang Menyerahkan, Yang Menerima,

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