RM 08b K

RSIA Perdana Medica Surabaya Nama Lengkap :……… …………............L / P

Jl. Kutisari No. 6 Surabaya
Tgl Lahir :...........................................................
Telp. (031) 8498311
Fax. (031) 8411140 No RM :
Email: rsiaperdanamedica@gmail.com

TRANSFER PASIEN INTRA HOSPITAL

Pengirim Tgl/jam Penerima Tgl/jam
Instalasi Nama Paraf transfer Instalasi Nama Paraf terima

Riwayat Penyakit Sekarang (Ringkasan Medis)

...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
Riwayat Penyakit dahulu
□ HT □DM □CVA □ Kolesterol □Asam urat □Jantung □............................ □.......................................
...................................................................................................................................................................................
Riwayat alergi
Obat Makanan Lain-lain Reaksi

Riwayat Operasi/Tindakan Lain

Kondisi sebelum ditransfer

TD Nadi RR Suhu SpO2 BB TB GCS Kesadaran Akral

Pemeriksaan fisik

Diagnosa

Indikasi Transfer
□ MRS □ Alih Ruang rawat □ Tindakan ............................................................................
Nama Dokter
DPJP Konsulan 1 Konsulan 2 Konsulan 3 Konsulan 4 Konsulan 5

Resume dan Rencana Pelayanan

Tgl/Jam Informasi Catatan Advis/Tindakan/Pengobatan Paraf
 RM 08b K
Nama
Tgl/Jam Informasi Catatan Advis/Tindakan/Pengobatan
& Paraf

(isi dengan advis dokter, tindakan yang sudah dilakukan, obat yang sudah diberikan, obat/ tindakan yang dilanjutkan
dan Rencana pelayanan lain)

Kondisi setelah ditransfer

TD Nadi RR Suhu SpO2 BB TB GCS Kesadaran Awal

Petugas Medis Nama Petugas Instalasi Paraf

Pengirim

Penerima

selesai serah terima pasien pukul:............................