Formulir Transfer Pasien.docx

RUMAH SAKIT GRAHA HERMINE Komplek Ruko Asih Raya No. 06 – 15 Batu Aji, Batam Telp. (0778) 363 318, 363 127 Fax (0778) 363 164 Email : [email protected]

FORMULIR TRANSFER PASIEN Nama Pasien

: ........................................ Jenis Kelamin

: ..............................

Tanggal Lahir

: ........................................ Tanggal Masuk

: ..............................

DPJP

: ........................................ Ruang / Kamar

: ..............................

Dokter Konsulen 1

: ....................................... Tanggal / Jam Pindah

: ..............................

Dokter Konsulen 2

: ....................................... Pindah ke Ruang / Kamar : ..............................

Diagnosis Masuk

: ........................................ Diagnosis Sekarang

: .................................

I.RINGKASAN RIWAYAT PASIEN Anamnesis 

Keluhan Utama

: ....................................................................................................... ....................................................................................................... .......................................................................................................



RiwayatPenyakit : ...................................................................................................... ....................................................................................................... .......................................................................................................



Pemeriksaan Fisik : ....................................................................................................... .......................................................................................................



Pemeriksaan tanda tanda vital : Tensi : ….. mmHg, Suhu: …..0C, Nadi: …..x/mnt



Keadaan Umum

: ........................................................................................................



Alasan Transfer

: .......................................................................................................

II.PEMERIKSAAN PENUNJANG YANG SUDAH DILAKUKAN ............................................................................................................................................ ............................................................................................................................................

III.TINDAKAN MEDIS YANG SUDAH DILAKUKAN ............................................................................................................................................. .............................................................................................................................................

IV.PEMBERIAN TERAPI 

Infus

: .................................................................................................................... ....................................................................................................................

...... Obat Injeksi : 1.

................................................................

4. ...........................................................

2.

................................................................

5. ............................................................

3.

................................................................

6. ...........................................................



Obat Oral :

1.

................................................................

4. ...........................................................

2

...............................................................

5. ...........................................................

3

................................................................

6. ...........................................................



Derajat Kebutuhan Perawatan Pasien



Derajat 0



Derajat 1



Derajat 2



Derajat 3

KATEGORI PASIEN TRANSFER Level

Kategori

Pendamping

Derajat 0

Pasien membutuhkan ruang perawatan biasa

TPK/Petugas Keamanan

Derajat 1

Derajat 2

Derajat 3

Peralatan Semua rekam medik, hasil pemeriksaan penunjang, format transfer internal

Pasien beresiko mengalami pemburukan, pasien baru pindah Peralatan derajat 0+ tabung Petugas PK 1/ dari HCU/ICU, pasien yang akan oksigen dan canul, stand Petugas Keamanan dirawat diruang perawatan tim infus dan pulse oksimetri. perawatan khusus. Pasien memerlukan pengawasan Peralatan derajat 1, + ketat atau intervensi khusus, mis: Dokter/Perawat PK bedside monitor, syringe pada pasien yang mengalami II pump. satu kegagalan sistem organ. Pasien mengalami kegagalan multi organ dan memerlukan Dokter/Perawat PK Peralatan derajat 2, + alat bantuan hidup jangka panjang III bantu nafas. ditambah dengan kebutuhan akan alat bantu nafas.

V. KONDISI PASIEN Sebelum Transfer Keadaan Umum : ................................. Kesadaran : ................................. Pemeriksaan Tanda - Tanda Vital :

Setelah Transfer Keadaan Umum : Kesadaran : Pemeriksaan Tanda - Tanda Vital :

Tensi : mmHg 0 Suhu : C Nadi : x/mnt Catatan Penting : ...................................................................

Tensi : mmHg 0 Suhu : C Nadi : x/mnt Catatan Penting : ...................................................................

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