Rm Ugd 1.docx
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CATATAN TERINTEGRASI TRIAGE UNIT GAWAT DARURAT/EMERGENCY ROOM UPT. PUSKESMAS BANJARANGKAN I
No RM :...................................................................... Nama Pasien :...................................................................... Jenis Klamin:....................................................................... Umur :...................................................................... Alamat :......................................................................
Tanggal :........./........./......... Jam Kedatangan :......... ......... WITA Waktu Pengkajian :......... ......... WITA
Dokter Pemeriksa :................................................ Perawat Pengkaji :................................................ Rujukan :................................................
Katagori Triage : merah hijau
kuning hitam
Riwayat Alergi :
Nama KK :......................................................................... Nama Pengantar :................................................................. Umur :................................................................ No Telp :................................................................
Jenis Kunjungan :
PBI
NON
TUNAI
Keluhan Utama :
Tanda-Tanda Vital dan Kesadaran Umumaa TD :......../........ N :........ RR :........ S :........ oC Pengkajian Nyeri Nyeri :.............................................................................................................................................................................. Skala Nyeri :
Keterangan : 0 : Nyaman 1-3 : Nyeri Ringan
4-6 : Nyeri Sedang 7-10 : Nyeri Berat
Level Kesadaran (GCS) : E........V........M........ Diagnosa :.................................................................................................................. ................................................................. Tindakan Lanjut : Resusitasi Bedah Non Bedah Poliklinik ............................................ VK Lain-lain ...........................
Dokter Triage
(.............................................)
(.............................................)
Perawat Triage
(.............................................)
No RM :...................................................................... Nama Pasien :...................................................................... Jenis Klamin:....................................................................... Umur :...................................................................... Alamat :......................................................................
Tanggal :........./........./......... Jam Kedatangan :......... ......... WITA Waktu Pengkajian :......... ......... WITA
Dokter Pemeriksa :................................................ Perawat Pengkaji :................................................ Rujukan :................................................
Katagori Triage : merah hijau
kuning hitam
Riwayat Alergi :
Nama KK :......................................................................... Nama Pengantar :................................................................. Umur :................................................................ No Telp :................................................................
Jenis Kunjungan :
PBI
NON
TUNAI
Keluhan Utama :
Tanda-Tanda Vital dan Kesadaran Umumaa TD :......../........ N :........ RR :........ S :........ oC Pengkajian Nyeri Nyeri :.............................................................................................................................................................................. Skala Nyeri :
Keterangan : 0 : Nyaman 1-3 : Nyeri Ringan
4-6 : Nyeri Sedang 7-10 : Nyeri Berat
Level Kesadaran (GCS) : E........V........M........ Diagnosa :.................................................................................................................. ................................................................. Tindakan Lanjut : Resusitasi Bedah Non Bedah Poliklinik ............................................ VK Lain-lain ...........................
Dokter Triage
(.............................................)
(.............................................)
Perawat Triage
(.............................................)
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