No.

RM:
RSKD IBU DAN ANAK SITI FATIMAH Nama Pasien:
Jl. Gunung Merapi No.75 Tanggal Lahir:
Alamat:
Kel. Lajanggiru, kec.ujung pandang
Makassar,Sulawesi selatan
Telp.(0411)3624956, 3620803
Fax (0411) 3625784
ASESMEN GAWAT DARURAT

Tanggal : Jam Datang :

1. Triage
Prioritas Triage : 1 2 3 4 5
 Trauma  Non trauma
Cara Pasien Datang :  Sendiri  Diantar : …………………………
Agama :
Suku :
Pekerjaan :
Status Menikah :

2. Asesmen Keperawatan
a. Data Subjektif :  Auto-anamnesis  Allo-anamnesis
Keluhan Penyakit : _____________________________________________________________
Riwayat Penyakit Dahulu : _____________________________________________________________
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Riwayat Alergi :  Ada  Tidak Ada
b. Data Objektif
Keadaan Umum :  Baik  Sedang  Buruk
Suhu :...... C
o
Nadi :……x/mnt Pernafasan :……x/mnt Tekanan Darah :………mmHg
Saturasi O2 :……% Berat Badan :……kg
c. Nilai Nyeri : (Tidak Ada Nyeri – Nyeri Sangat Berat)
1) Skala Wong Baker  Skor :……

2) VAS (Visual Analogue Scale)  Skor:……

3) BPS (Behavioral Pain Scale)  Skor <5  Skor >5

4) FLACCS (Face, Leg, Activity, Cry, Consolability)  Skor <5  Skor >5
d. Asesmen Resiko Jatuh
 Humpty Dumpty  Morse Fall Scale  Geriatri Skor :……
e. Masalah
Keperawatan :_________________________________________________________
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f. Rencana Tindakan
Keperawatan :_________________________________________________________
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Tanggal :……………… Jam :…………

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Tanda Tangan dan Nama Lengkap Perawat
3. Asesmen Medis (Dokter)
a. Anamnesis
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b. Pemeriksaan Fisik
GCS: E____M____V____
Suhu :……oC Nadi :……x/mnt Pernafasan :……x/mnt Tekanan Darah :………… mmHg

c. Pemeriksaan Penunjang :________________________________________________________________

d. Diagnosa Kerja :________________________________________________________________
e. Diagnosa Banding :________________________________________________________________
f. Tindakan dan Pengobatan:________________________________________________________________
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g. Rencana Pelayanan :  Preventif  Kuratif  Rehabilitatif  Pelayanan Spesialistik
 Paliatif  Pelayanan Intensif

h. Tindak Lanjut :  Rawat Jalan  Rawat Inap : Rg. Perawatan / ICU / OK / VK

Rujuk  Pulang Atas Permintaan Sendiri  Meninggal

i. Kondisi Medis/Masalah Medis Saat : Pulang / Pindah Rg Perawatan / OK / VK / Rujuk :

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Tanggal :……………… Jam :…………