Rumah Sakit Umum Medika Djaya RM.C.

15
Jl. Parit Haji Husin 1, Blok MD No. 1
Pontianak Tenggara - Kalimantan Barat Indonesia
Kodepos 78124. Tlp. 0561-5688463, 5688558, 5688437
Email : rsmedikadjaya@gmail.com

FORMULIR TRANSFER PASIEN

Diagnosa : ______________________________________________________________________________________________________
Dokter yang merawat : 1. _______________________________________________________
2. _______________________________________________________
3. _______________________________________________________
Tgl masuk RS : ______________________________ Hari/Tgl/Jam Pindah : _______________ /____________ /________
Asal ruangan : ______________________________ Ruangan yang dituju : ______________________________________
Penanggung Jawab Pembayaran :
Pribadi Asuransi Swasta BPJS
Perusahaan _________________________________________ Lain –lain : __________________________________________
I. TINDAKAN KHUSUS/OPERASI, DAN LAIN-LAIN :
1. ____________________________________________________________________________________________________________________
2. ____________________________________________________________________________________________________________________
II. PEMERIKSAAN FISIK
KU : TSR / TSS / TSB TD : ________ MmHg, Nadi : _______ x/mnt, RR : _______ x/mnt, Suhu : ______ °C
Kesadaran : _____________________ GCS : ________ E : ________ M : ________ V : ________ Pupil : ________
Skala nyeri : Tidak ada nyeri Nyeri ringan Nyeri sedang Nyeri berat
Lokasi nyeri : _____________________________________________________________________________________________________
Resiko Jatuh : Resiko rendah Resiko tinggi
III. PROGRAM PEGOBATAN DAN PERAWATAN
Oksigen : ______________ ltr/menit , kanul binasal / Non-Rebreathing Mask / Tracheostube / ETT / OPA
Terapi Cairan : 1. _______________________________________ 3. ________________________________________
2. _______________________________________ 4. ________________________________________
Kateter IV No : _____________________________ Dipasang Tgl : _______________________________________
Kateter Foley No : _____________________________ Dipasang Tgl : _______________________________________
NGT No : _____________________________ Dipasang Tgl : _______________________________________
Fisioterapi : __________________________________________________________________________________________
Mobilisasi : __________________________________________________________________________________________
Perawatan Luka Op : __________________________________________________________________________________________
Drainase : __________________________________________________________________________________________
Diet : __________________________________________________________________________________________
Diagnosa Keperawatan : __________________________________________________________________________________________

Terapi Injeksi Terapi Oral

Nama Obat IV/ Jml Jam Nama Obat Jml Jam
No Dosis No Dosis
Injeksi IM Obat Pemberian Oral dan lain-lain Obat Pemberian
1 1
2 2
3 3
4 4
5 5
6 6
7 7

IV. BARANG-BARANG YANG DISERAH TERIMAKAN

Status Lengkap Rontgent CT Scan USG Lain-lain : __________________________________

Yang Menyerahkan, Yang Menerima,

( __________________________________ ) ( __________________________________ )
Nama jelas dan tanda tangan Nama jelas dan tanda tangan

21/RM/RSMD/FORM/V/2022 REVISI : 00