MONITORING PASIEN DI AMBULANS

Nama : NOMOR REKAM MEDIS

Tanggal Lahir :

Jenis Kelamin :

Alamat : Ruang :

Dari : ..............................................................................................................................
Tanggal : ..............................................................................................................................
Dokter yang merawat : ..............................................................................................................................
Indikasi MRS : ..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
Riwayat Penyakit : ..............................................................................................................................
..............................................................................................................................
Pemeriksaan Fisik
Keadaan Umum : Sakit ringan / sedang / berat ...................................................(sesuai keadaan)
Kesadaran : ......................GCS............................................DJJ...............................................
Pemeriksaan Penunjang :

Diagnosis Medis :
Prosedur yang dilakukan :
Infus Tanggal : ....................................................................................................................................
NGT Tanggal : ....................................................................................................................................
Kateter tanggal : ....................................................................................................................................
O2 : ....................................................................................................................................
Riwayat alergi : ....................................................................................................................................
Obat obatan yang diberikan :
Nama Obat Dosis Jumlah Aturan Obat Cara Pemberian

Tindakan lain yang akan dilakukan :

..........................................................................................................................................................................
..........................................................................................................................................................................
Keadaan pasien waktu pindah :
Kesadaran: .................................... GCS: ................................. TD: .......................... Nadi: .........................
Pernafasan :................................... Suhu: ............................... BB: ........................Kg TB : ........................cm

Petugas yang menerima Petugas yang menyerahkan

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