FORM PERTOLONGAN PERTAMA PADA KECELAKAAN

PUSKESBUN
PTPN VII UNIT WAY LIMA
\\

BIO DATA PENILAIAN DINI

Nama Pasien :………………………………..L/ P Kesan Umum : Trauma / Medis

Alamat : ............................................. Respon : Awas / Suara / Nyeri / Tidak
Respon
Nama Saksi : ………………………………..L/ P
No. BPJS : ............................................. Nafas : Ada / Tidak
No. HP : ............................................. Nadi : Ada / Tidak
Perdarahan Besar : Ada / Tidak

JENIS LUKA
1. ..........................................................................
2. ..........................................................................
3. ..........................................................................
TINDAKAN PERTOLONGAN YANG
DILAKUKAN:
1. ..........................................................................
..........................................................................
2. ..........................................................................
..........................................................................
3. ..........................................................................
..........................................................................

TANDA VITAL KETERANGAN :

Frekuensi Nafas : / menit

Frekuensi Nadi : / menit = Pendarahan

Tekanan Darah : mmhg = Luka

Suhu : ºC
= Patah Tulang

KOMPAK :
Keluhan Utama : .......................................................................................................
Obat Terakhir : ......................................................................................................
Makanan / Minuman Terakhir : .......................................................................................................
Penyakit yang diderita : .......................................................................................................
Alergi yang diderita : .......................................................................................................
Kejadian : ......................................................................................

KETERANGAN :

Dirujuk ke : Rumah Sakit / Puskesmas / Dokter / lainnya.

Transportasi : Ambulance / Kendaraan Kantor / Kendaraan Pribadi
Inventaris korban : .......................................................................................................
.......................................................................................................
Pesawaran, ………………………………..
Petugas Medis

( ………………………….. )
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 FORM PERTOLONGAN PERTAMA PADA KECELAKAAN
PUSKESBUN
PTPN VII UNIT WAY LIMA
\\
 FORM PERTOLONGAN PERTAMA PADA KECELAKAAN
PUSKESBUN
PTPN VII UNIT WAY LIMA
\\

BIO DATA PENILAIAN DINI

Nama Korban........................................................L/ P Kesan Umum : Trauma / Medis

Alamat : ............................................. Respon : Awas / Suara / Nyeri /
Nama Saksi............................................................L/ P Tidak Respon
Alamat : ............................................. Nafas : Ada / Tidak
Phone : ............................................. Nadi : Ada / Tidak
Perdarahan Besar : Ada / Tidak

JENIS LUKA

1. ..........................................................................
2. ..........................................................................
3. ..........................................................................
TINDAKAN PERTOLONGAN YANG
DILAKUKAN:
1. ..........................................................................
..........................................................................
2. ..........................................................................
..........................................................................
3. ..........................................................................
..........................................................................

TANDA VITAL
Frekuensi Nafas :......................../ menit KETERANGAN :
Frekuensi Nadi :......................../ menit
Suhu : Normal / Panas /
Dingin = Pendarahan
Kondisi Kulit : Lembab / Kering /
Pucat / Normal / = Luka
Kebiruan / Berkeringat
= Patah Tulang

KETERANGAN :

Dirujuk ke : Rumah Sakit / Puskesmas / Dokter / lainnya.

Transportasi : Ambulance / Becak / lainnya
Inventaris korban : .......................................................................................................
.......................................................................................................

Majalengka, ………………………………..

Petugas Penolong

( ………………………….. )