*Coret yang

tidak perlu

Alamat : ......................................... No. RM :

Tgl Masuk : ..........................Jam : ....... Nama Pasien : ………………. Jenis Kelamin :L/P

Ruang/ Kelas : ......................./............... Tgl Lahir : ........................./........Thn / Bln /

Hr
CATATAN AMBULAN DAN EVAKUASI
A. Permintaan Ambulan Internal
Diagnosa rujukan : ............................................................................... Alasan rujuk / pindah : ................................................................
Tanggal / jam permintaan : ............................................/.......................... WIB Dokumen yang disiapkan : ................................................................
Tanggal / jam berangkat : ............................................/.......................... WIB
Resume Medis/ Rujuk Hasil Lab dan Radiologi
Dokter penanggung jawab : .............................................................................
Asal ruangan : ........................................................................... Nama petugas RS tujuan yang menyetujui : ..........................................

B. Permintaan Ambulan External

No. telp yang menghubungi : ........................................................................... Tanggal / jam berangkat : ..................................../ ................... WIB
Alasan penjemputan : ........................................................................... Tanggal / jam tiba di RS : ..................................../ ................... WIB
Tanggal / jam permintaan : ............................................./ ..................... WIB Cek kebenaran telp dengan menghubungi kembali
Sarana Evakuasi Cek ketersediaan ruangan sesuai indikasi pasien
Ambulan Non Ambulan .............................................
Petugas Evakuasi
1. .................................................. 3. ....................................................
2. .................................................. 4. ....................................................
Alasan Trasnportasi
Rujuk ke RS ........................... Pindah ke RS ........................... APS Dipulangkan Lainnya, ……................
Keluhan Utama : .........................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................
TRIAGE
Merah Kuning Hijau Hitam
Jenis Transportasi
Emergency Non Emergency
SURVEI PRIMER Jam : ....................
Airway Breathing Exposure
Patent Spontan Luka terbuka
Obstruksi Total Tachypnoe Benda asing yang menancap
Obstruksi Pasrsial Kusmaul Hipotermia
Bradypnoe Heat stroke
Apnoe
DAFTAR MASALAH / KONDISI KHUSUS : ...........................................................................................................................................................................
.........................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................
......
Airway Breathing Circulation Exsposure Peralatan

Oropharyngeal Tube Nasal Canule ..................Lpm IVFD ( Jenis Cairan ) Bebat tekan Monitor Infus
Endo Tracheal Tube Simpel Mask ...................Lpm 1. ...................Tpm/..........cc Bidai Pump Syringe
Nasopharingeal Tube Non Rebreathing Mask....Lpm 2. ...................Tpm/..........cc Immobilasi Penuh Pump
Lain-lain................ Rebreathing ....................Lpm 3. ...................Tpm/..........cc Cegah hipotermia
.................................... Venturi Mask ..................Lpm
Folley Catheter No..... Cervical collar
Lain-lain ................................
NGT No............... Lain-lain........

CATATAN OBSERVASI

Jam
BP (mmhg) RR Sp02 Nadi Kulit Skala Koma Glasgow
Jam Menit

...................... x / Mnt Warna :........ Dingin/Hangat E.... M.... V...... Eyes :

Reguler Kuat Kering/Basah Score : .............. 1. Tidak respon
Irregular Lemah Suhu
0
:...... C 2. Rangsang nyeri
3. Panggilan
...................... x / Mnt Warna :........ Dingin/Hangat E.... M.... V...... 4. Spontan
Reguler Kuat Kering/Basah Score : ..............
Irregular Lemah Suhu
0
:...... C
...................... x / Mnt Warna :........ Verbal :
Dingin/Hangat E.... M.... V......
Reguler Kuat 1. Tidak bicara
0
Kering/Basah Score : .............. 2. Tidak mengerti
Irregular Lemah Suhu :...... C
3. Kacau
...................... x / Mnt Warna :........ Dingin/Hangat E.... M.... V...... 4. Bingung
Reguler Kuat Kering/Basah Score : .............. 5. Terarah
0
Irregular Lemah Suhu :...... C

Keterangan :
Berilah tanda ( √ ) pada tanda untuk pilihan yang sesuai
DRM 53

Ha 1/1
 Jam
BP (mmhg) RR Sp02 Nadi Kulit Skala Koma Glasgow
Jam Menit

...................... x / Mnt Warna :........ Dingin/Hangat E.... M.... V...... Motorik :

Reguler Kuat Kering/Basah Score : .............. 6 Ikut perintah
Irregular Lemah Suhu
0
:...... C 5 Rangsang nyeri
...................... x / Mnt Warna :........ Dingin/Hangat E.... M.... V...... 4 Menghindar
Reguler Kuat Kering/Basah Score : .............. 3 Fleksi
Irregular Lemah Suhu
0
:...... C 2 Extensi
...................... x / Mnt Warna :........ Dingin/Hangat E.... M.... V...... 1 Tidak Respon
Reguler Kuat Kering/Basah Score : ..............
0
Irregular Lemah Suhu :...... C
...................... x / Mnt Warna :........ Dingin/Hangat E.... M.... V......
Reguler Kuat Kering/Basah Score : ..............
0
Irregular Lemah Suhu :...... C
...................... x / Mnt Warna :........ Dingin/Hangat E.... M.... V......
Reguler Kuat Kering/Basah Score : ..............
Irregular Lemah Suhu
0
:...... C
...................... x / Mnt Warna :........ Dingin/Hangat E.... M.... V......
Reguler Kuat Score : ..............
Irregular Lemah 0 Kering/Basah
Suhu :...... C
...................... x / Mnt Warna :........ Dingin/Hangat E.... M.... V......
Reguler Kuat Kering/Basah Score : ..............
Irregular Lemah Suhu
0
:...... C
...................... x / Mnt Warna :........ Dingin/Hangat E.... M.... V......
Reguler Kuat Kering/Basah Score : ..............
0
Irregular Lemah Suhu :...... C
...................... x / Mnt Warna :........ Dingin/Hangat E.... M.... V......
Reguler Kuat Kering/Basah Score : ..............
0
Irregular Lemah Suhu :...... C
...................... x / Mnt Warna :........ Dingin/Hangat E.... M.... V......
Reguler Kuat Kering/Basah Score : ..............
0
Irregular Lemah Suhu :...... C
Jam
Obat-obatan Rute/ Dosis Urine Output Alergi
Jam Menit

Ya/ Tuliskan
……………………..
……………………..
……………………..
……………………..

Tidak ada

Perhatian khusus/ Catatan khusus

……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
SERAH TERIMA PASIEN

0
TD : ………..mmHg Nadi : …………x/menit T : ……..….. C RR : ………….x/menit

GCS : E ……… M ……… V …….

Nganjuk, …………………………… Jam : ……..
Petugas Ambulan Petugas/ Keluarga Penerima*

(…………………………………………) (…………………………………………)
Tanda Tangan & Nama Terang Tanda Tangan & Nama Terang
Hal 2/2