Form.docx
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FORMULIR SKRINING DARI LUAR RUMAH SAKIT BLUD RSUD NABIRE I. IDENTITAS PASIEN : a. Nama Pasien : b. Jenis Kelamin : c. Umur : d. Status Pembayaran :
Asal Rujukan : Alasan di rujuk :
II. DIAGNOSA
III. KEADAAN PASIEN a. Keadaan Umum : b. Kesadaran : c. Tanda – tanda vital : T :
mmHg, N :
x/i,
S:
0
C, P :
x/i
IV. PENATALAKSANAAN a. Terapi
b. Tindakan
V. HAND OVER □ Resusitasi □ Neuro VI. KETERANGAN □ TERIMA
□ Bedah □ Mata
□ Interna □ Jiwa
□ Kardio □ Obgyn □ Kul – Kel □ Anak
Nabire, □ TOLAK
2019 Petugas Jaga
Alasan (......................................) *
Nama jelas/stempel nama petugas
Asal Rujukan : Alasan di rujuk :
II. DIAGNOSA
III. KEADAAN PASIEN a. Keadaan Umum : b. Kesadaran : c. Tanda – tanda vital : T :
mmHg, N :
x/i,
S:
0
C, P :
x/i
IV. PENATALAKSANAAN a. Terapi
b. Tindakan
V. HAND OVER □ Resusitasi □ Neuro VI. KETERANGAN □ TERIMA
□ Bedah □ Mata
□ Interna □ Jiwa
□ Kardio □ Obgyn □ Kul – Kel □ Anak
Nabire, □ TOLAK
2019 Petugas Jaga
Alasan (......................................) *
Nama jelas/stempel nama petugas
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