RM.

42

PEMERINTAH KABUPATEN BATANG HARI

RUMAH SAKIT UMUM DAERAH
HAJI ABDOEL MADJID BATOE
Jl. Prof dr. Sri Sudewi, SH–Muara Bulian Telp(0743) 21043, Fax(0743) 21858
E-mail : rsudbulian@yahoo.co.id Kode Pos 36613

CATATAN MEDIS GAWAT DARURAT

NAMA : .................................... JK :LAKI-LAKI /PEREMPUAN PEKERJAAN : ...................................
UMUR : .................................... AGAMA : ......................................... NO. CM : ..................................

ALAMAT :......................................................................................................................................................................

1. TRIAGE
Prioritas Triage : 1 2 3 4
Trauma Non Trauma
Cara Pasien Datang : Sendiri Diantar,

2. PENGKAJIAN PERAWAT
A. Data Subjektif
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Riwayat Alergi : Tidak Ada Ada, ........................................................................................
Riwayat Penyakit Dulu :
............................................................................................................................................................................
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B. Data Objektif
Keadaan Umum : Baik Sedang Buruk
Nilai Nyeri / Pain Score :

0 1 2 3 4 5 6 7 8 9 10
Tekanan o
: mmHg Nadi : x/mnt Suhu : C
Darah
Saturasi
Pernapasan : x/mnt Berat Badan : kg : %
O2

Tanda Tangan & Nama Lengkap Perawat

Tanggal : / /
(………………………………………….) Jam : . wib

RSUD HAJI ABDOEL MADJID BATOE

 RM. 43
KABUPATEN BATANG HARI
3. PEMERIKSAAN DOKTER
A. Anamnesis
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B. Data Objektif
GCS : E M V
Normal Jika Tidak Normal, Jelaskan
Kepala
Mata
Mulut
Leher
Dada
Perut
Alat Gerak
Anus –
Genetalia

C. Diagnosa Kerja
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D. Diagnosa Banding
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E. Tindakan & Pengobatan
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F. Tindak Lanjut : Pulang Rawat Pulang Paksa Rujuk
Meninggal
G. Kesimpulan
..........................................................................................................................................................................
H. Disposisi Selanjutnya diteruskan ke Ruang : .................................Dokter :...........................................................
Tanda Tangan & Nama Dokter

Tanggal : / /
(………………………………….) Jam : . wib

RSUD HAJI ABDOEL MADJID BATOE

KABUPATEN BATANG HARI
 RM.42

PEMERINTAH KABUPATEN BATANG HARI

RUMAH SAKIT UMUM DAERAH
HAJI ABDOEL MADJID BATOE
Jl. Prof dr. Sri Sudewi, SH–Muara Bulian Telp(0743) 21043, Fax(0743) 21858
E-mail : rsudbulian@yahoo.co.id Kode Pos 36613

CATATAN PEMINDAHAN PASIEN DARI IGD DAN RAWAT JALAN

SITUATION
Nama : ………………………………………………… No. RM:……………………………………………………………...
Tiba Di Ruangan ...................................................................... Dari Ruangan ..........................................................................
Tanggal ........................................... Pukul .................. Diagnosa .................................................................................
Dokter Yang Merawat 1. dr. ....................................... 2. dr. ....................................... 3. dr. .......................................
Pasien / Keluarga Sudah Dijelaskan Mengenai Diagnosis : Ya Tidak
Alasan Masuk Ruang Rawat Inap : .........................................................................................................
..........................................................................................................
Prosedur Pembedahan Operasi Yang Akan / Sudah Di Lakukan : ..............................................................................................
Tanggal : ............................... Jam : ....................

BACKGROUND
Riwayat Alergi / Reaksi Obat : Ya, Nama Obat.................................................. Tidak
Riwayat Reaksi : .......................................................................................................................................................
Intervensi Medik / Keperawatan : .......................................................................................................................................................
Hasil Investigasi Abnormal : .......................................................................................................................................................
Kewaspadaan Precaution : Standard Contact Airborne Droplet
ASSESSMENT
Observasi Terakhir Pukul : ............................................................................................................................................................
GCS : E M V Pupil & Reaksi Cahaya : Kanan .................... Kiri ......................
TD : mmHg N : x/mnt RR : x/mnt Spo2 : % Suhu : 0
c Skala Nyeri ...............
Diet / Nutrisi : Oral NGT Puasa Jam : .......................
Batasan Cairan : cc Diet Khusus : ........................................................................
BAB : Normal Ileustomy / Colostomy Inkontinensia Urin Inkontinensia Alvi
BAK : Normal Kateter, Jenis : No : Tgl Pemasangan : ............................
Transfer / Mobilisasi : Mandiri Di Bantu Sebagian Di Bantu Penuh
Mobilisasi : Jalan Tirah Baring Duduk
Gangguan Indera : Tidak Ada Bicara Pendengaran Penglihatan Penciuman Perabaan
Alat Bantu Yang Di Gunakan : Tanpa Alat Bantu Gigi Palsu Kaca Mata Alat Bantu Dengar
Infus : Tidak Ya, Lokasi :............................................ Tgl Pemasangan ..............................
Hal – Hal Istimewa Yang Berhubungan Dengan Kondisi Pasien
............................................................................................................................................................................................................
............................................................................................................................................................................................................
Tindakan / Kebutuhan Khusus : Protokol Resiko Pasien Jatuh Protokol Restrain Perawatan Luka Hygiene
 RM. 43
Peralatan Khusus Yang Diperlukan ......................................................................................................................................................
............................................................................................................................................................................................................
RSUD HAJI ABDOEL MADJID BATOE
KABUPATEN BATANG HARI
RESUME

Konsultasi
......................................................................................................................................................................................
......................................................................................................................................................................................
Therapy
......................................................................................................................................................................................
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......................................................................................................................................................................................
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Rencana Pemeriksaan Lab Radiology
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......................................................................................................................................................................................
Fisio Theraphy Mobilisasi
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......................................................................................................................................................................................
Rencana Tindakan Lebih Lanjut
......................................................................................................................................................................................
......................................................................................................................................................................................
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Note : Obat, Barang, Dokumen Yang Diserahkan
Hasil Permintaan Administrasi Form Catatan Terintegrasi
Laboratorium Formulir Konsultasi Spesialis IMR
Foto X-Ray Konfirmasi Spesialis Rujukan Dari Dokter RS
CT Brain Form Rawat Inap Obat-Obatan
USG Konfirmasi Dokter RMO Konfirmasi BO Tindakan Cito
Mri / Mra EKG Inform Consent
ECHO Gelang Nama Lain-Lain : ..............................................................

Diketahui Diserahkan Diterima

Dokter Jaga Perawat ETC / OPD Perawat Ruangan

(………………………………….) (………………………………….) (………………………………….)

RSUD HAJI ABDOEL MADJID BATOE

KABUPATEN BATANG HARI
 RM.42

PEMERINTAH KABUPATEN BATANG HARI

RUMAH SAKIT UMUM DAERAH
HAJI ABDOEL MADJID BATOE
Jl. Prof dr. Sri Sudewi, SH–Muara Bulian Telp(0743) 21043, Fax(0743) 21858
E-mail : rsudbulian@yahoo.co.id Kode Pos 36613

CATATAN PEMINDAHAN PASIEN ANTAR RUANGAN

SITUATION
Nama : ………………………………………………………………. No.RM : ……………………………………………………………
Pemindahan Dari Ruangan ...................................................... Dipndahkan Ke Ruangan .........................................................
Asal Kelas ............................ Ke Kelas............................... Tanggal ........................................ Pukul............................
Dokter Yang Merawat 1. dr. ....................................... 2. dr. ....................................... 3. dr. .......................................
Diagnosis Medis...................................................................................................................................................................................
Pasien / Keluarga Sudah Dijelaskan Mengenai Diagnosis : Ya Tidak
Alasan Masuk Ruang Rawat Inap : .........................................................................................................
.......................................................................................................
Prosedur Pembedahan Operasi Yang Akan / Sudah Di Lakukan : .........................................................................................................
Tanggal : .................................. Jam : .......................
BACKGROUND
Riwayat Alergi / Reaksi Obat : Ya, Nama Obat.................................................. Tidak
Riwayat Reaksi : .................................................
Intervensi Medik / Keperawatan : .......................................................................................................................................................
Hasil Investigasi Abnormal : .......................................................................................................................................................
Kewaspadaan Precaution : Standard Contact Airborne Droplet
ASSESSMENT
Observasi Terakhir Pukul : ........................................... Tingkat Kesadaran : ..................................................................
GCS : E M V Pupil & Reaksi Cahaya : Kanan .................... Kiri ......................
TD : mmHg N : x/mnt RR : x/mnt Spo2 : % Suhu : 0
c Skala Nyeri ...............
Diet / Nutrisi : Oral NGT Puasa Jam : .......................
Batasan Cairan : cc Diet Khusus : ........................................................................:

BAB : Normal Ileustomy / Colostomy Inkontinensia Urin Inkontinensia Alvi

BAK : Normal Kateter, Jenis : No : Tgl Pemasangan : ............................
Transfer / Mobilisasi : Mandiri Di Bantu Sebagian Di Bantu Penuh
Mobilisasi : Jalan Tirah Baring Duduk
Gangguan Indera : Tidak Ada Bicara Pendengaran Penglihatan Penciuman Perabaan
Alat Bantu Yang Di Gunakan : Tanpa Alat Bantu Gigi Palsu Kaca Mata Alat Bantu Dengar
Infus : Tidak Ya, Lokasi :............................................ Tgl Pemasangan ..............................
Tindakan / Kebutuhan Khusus : Protokol Resiko Pasien Jatuh Protokol Restrain Perawatan Luka Hygiene
Peralatan Khusus Yang Diperlukan 1. .......................................................... Lama Penggunaan : ..........................................
 RM. 43
2. .......................................................... Lama Penggunaan : ..........................................
3. .......................................................... Lama Penggunaan : ..........................................
4. .......................................................... Lama Penggunaan : ..........................................

RSUD HAJI ABDOEL MADJID BATOE

KABUPATEN BATANG HARI
Hal – Hal Istimewa Yang Berhubungan Dengan Kondisi Pasien
............................................................................................................................................................................................................
............................................................................................................................................................................................................
............................................................................................................................................................................................................

Diagnosa Keperawatan Sudah Teratasi Belum Teratasi

1. ........................................................................................................................................
2. ........................................................................................................................................
3. ........................................................................................................................................
4. ........................................................................................................................................
5. ........................................................................................................................................

RESUME

Konsultasi
............................................................................................................................................................................................................
Therapy
............................................................................................................................................................................................................
............................................................................................................................................................................................................
............................................................................................................................................................................................................
............................................................................................................................................................................................................
............................................................................................................................................................................................................
............................................................................................................................................................................................................
Rencana Pemeriksaan Lab Radiology
............................................................................................................................................................................................................
Fisio Theraphy Mobilisasi
............................................................................................................................................................................................................
Rencana Tindakan Lebih Lanjut
............................................................................................................................................................................................................
............................................................................................................................................................................................................
Note : Obat, Barang, Dokumen Yang Diserahkan
Obat-obatan sesuai IMR pasien MRI Lembar ECHO
Hasil Lab Lembar MRA Lembar Gigi Palsu
Foto Rontgen Lembar Hasil USG Lembar Kaca Mata
CT Scan Lembar Surat Jaminan Lembar
Rekam Medis Lama : Ada Tidak lain –lain, ....................................................................

Disetujui Mengetahui Diserahkan Diterima Dibukukan

 RM.42

Pasien/Keluarga Dokter Perawat Perawat Administrasi

RSUD HAJI ABDOEL MADJID BATOE
KABUPATEN BATANG HARI