Chase Plaza 22nd Floor | Jl. Jend. Sudirman Kav 21, Jakarta 12920 |Email: customer@bcalife.co.id
*Harap melengkapi poin 5 jika mengambil manfaat Gawat Darurat/Please complete point 5 if taking emergency benefit.
c Apakah diagnosa di atas disebabkan/merupakan komplikasi dari/berhubungan dengan
Is the diagnose caused by/complication of/related to :
Kejiwaan / psikosomatis Kosmetik /Bedah Plastik
Hormonal
Psychologic/psychosomatic Cosmetic/Plastic surgery
Penyakit Hubungan Seksual
Maternity HIV or AIDS
Sexually Transmitted Diseases
Kelainan tumbuh kembang
Refraksi/Refraction Lainnya/Others :
Developmental disorders
Jika ada jawaban “Ya” satu atau lebih, mohon sebutkan dan jelaskan*/If the answer is “Yes” one or more, please state and explain*
Mohon sebutkan nama dan alamat dokter/rumah sakit yang pernah dikunjungi oleh pasien jika pasien ini merupakan rujukan dari
4 tempat lain
Please state the name and address of doctors/hospitals if the patient is a refferal from another doctors/hospitals.
PT Asuransi Jiwa BCA terdaftar dan diawasi oleh Otoritas Jasa Keuangan
OP/CL/0602/031503
5 Kondisi Gawat Darurat /Emergency Condition
A. Informasi Medis Umum/Medical General Information:
1. Sebutkan gejala dan keluhan yang mendukung diagnosa ini/Please specify the patient’s chief symptoms and complaints
due to the diagnose: .........................................................................................................................
..............................................................................................................................................................................
2. Mohon jelaskan hasil pemeriksaan fisik yang dilakukan/Please describe the results of physical examination performed :
Tanda vital/Vital sign :
- Suhu tubuh/Temprature : ..........................................°C
- Tekanan Darah/Blood Pressure : ................../...................mmHg
- Nafas/Breath : .....................................X/minute
- Pemeriksaan fisik/Physical examination :
B. Rincian Medis untuk kondisi Gawat Darurat/ Medical details for emergency condition :
1. Diare dan Muntah Profus/Profuse diarrhea and vomiting :
- Apakah diare sudah terjadi > 10x perhari/Has diarrhea happened > 10x perday? ................................................
- Apakah Muntah sudah terjadi > 6x perhari/Has vomiting happened >6x perday ? ................................................
- Apakah telah terjadi dehidrasi/Has dehydration happened ? ..................................................................................
2. Anuria(tidak buang air kecil)/Anuria :
- Sudah berapa jam pasien tidak buang air kecil dalam sehari/How many hours of patient does not urinate in a day?
....................................................................................................................................................................................
3. Sesak Nafas, Kejang disertai penurunan kesadaran, Tumor otak/Shortness of breath, seizures accompanied by loss of
conciousness, brain tumors
- Nilai Glasgow Coma Scale (GCS)/ Glasgow Coma Scale (GCS) grade: ..................................................................
- Apakah terjadi penurunan kesadaran/Was there a loss of consciousness ?
□ Apatis/Apathetic □ Somnolent □ Sopor □ Sopor Coma □ Coma
- Apakah terjadi sianosis/Has cyanosis happened ? ...................................................................................................
- Apakah terjadi retraksi hebat atau penggunaan otot pernafasan sekunder/Whether there was severe retraction or use
of secondary respiratory muscles ? ............................................................................................................................
- Mohon sebutkan hasil interpretasi CT Scan/MRI kepala (atau tehnik pencitraan lainnya)/Please describe the result of
head CT scan/MRI (or other technical imaging):
.....................................................................................................................................................................................
(*mohon lampirkan hasil pemeriksaan/please attach the report)
4. Cardiac arrest :
- Hasil interpretasi pemeriksaan EKG/Electro Cardio Graphy (ECG)result :
...................................................................................................................................................................................
(*mohon lampirkan hasil EKG/Please attach the report)
5. Anemia :
- Mohon jelaskan kondisi klinis pasien tersebut/Please describe the patient’s clinical condition :
..................................................................................................................................................................................
..................................................................................................................................................................................
- Jumlah haemoglobin dalam darah/The amount of haemoglobin : ........................g/%
(*mohon lampirkan hasil laboratorium/Please attach the report)
Ditandatangani di Tanggal
- -
Signed in: Date:
Nama Dokter Tanda Tangan
Doctor’s Name: Sign:
No Telp/HP
Phone Number:
Ahli/Kualifikasi
Specialist:
Nama RS Stempel RS
Hospital: Hospital’s Stamp:
Alamat RS
Address:
PT Asuransi Jiwa BCA terdaftar dan diawasi oleh Otoritas Jasa Keuangan
OP/CL/0602/031503