RUMAH SAKIT UMUM TRIMEDIKA KETAPANG

Jl. Pangeran Puger (Jalan Raya Purwodadi-Pati Km. 6), Grobogan,

Jawa Tengah. Telp (0292) 5140267

PERMINTAAN DARAH UNTUK TRANSFUSI

Nomor RM : ...................................................................................................................
Rumah Sakit : ........................Ruang..................................Kelas......................................
Dokter yang meminta : ...................................................................................................................
Nama pasien : ............................................................................L/P, Umur...................th
Alamat pasien : ..................................................................................................................
Diagnosa (sementara) : ...........................................................Indikasi tegas..................................
Diperlukan Tgl. : ..................................................................................Jam...........................
Transfusi sebelumnya : ................................................................Kapan.................Gol..................
Untuk pasien wanita/Pria : Pernah hamil.........................Abortus..............................Partus................
Jenis darah yang diperlukan : Gol. Darah
1. Whole Blood segar/biasa : ............................................cc
2. Packed Red Cell : ............................................cc
3. Plasma : ............................................cc
4. Tromcyte Concentrate (TC) : ............................................cc
5. Washed Erythrocyt (WE) : ............................................cc
6. Buffy Coat (PC) : ............................................cc

HAL-HAL LAIN Grobogan, .........................................20

............................................................ Tanda tangan Dokter yang meminta
............................................................
............................................................

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CATATAN
Harap diisi yang lengkap
Yang tidak diisi lengkap akan dikembalikan

Diisi oleh Unit Donor Darah PMI Cabang Grobogan

Telah kami kirimkan : ................................ (................................) kolf darah gol .......................
Untuk pasien tsb. Nama : ..................................................Gol ...........................................................
Membutuhkan darah : .................................................Cc giving – set .........................................
Dengan nomor kolf : ............................................................
: ............................................................
Nomor crossmatch : ............................................................
Compatibility test : Nomor CM............................
Grobogan, ...................... 20
Fase I : Tanda tangan Tanda tangan
Fase II : Yang mengerjakan Penerima
Fase III :
Enzym test :

(...............................) (...............................)
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