Form Hand Over Antar Shift / Serah Terima Antar shift Jaga

FASHARKAN TNI AL MANOKWARI RUMKITAL dr. AZHAR ZAHIR

FORMULIR SERAH TERIMA ( H A N D RUANGAN

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

HARI, TANGGAL

OVER )

ANTAR SHIFT JAGA Nama Pasien : ...........................................................

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

PAGI

Tgl Lahir

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

No. RM

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

SORE

MALAM

Situation :................................................................... ................................................................................... ...................................................................................

Situation :................................................................... ................................................................................... ...................................................................................

Situation :................................................................... ................................................................................... ...................................................................................

Background :............................................................. ..................................................................................

Background :............................................................. ..................................................................................

Background :............................................................. ..................................................................................

Dx. Medis :................................................................

Dx. Medis :................................................................

Dx. Medis :................................................................

DPJP: dr....................................................................

DPJP: dr....................................................................

DPJP: dr....................................................................

 Assesment :........... :.................... ................... ................... .................. ................... .............. ....

Assesment :......... :................... ................... ................... ................... .................. ............... ......

Assesment :.......... :.................... ................... ................... ................... ................... .............. ....

Kesadaran Kesadara n :............... ............... .......GCS:..... ...........

Kesadaran :............. ................ ........GCS:... .............

Kesadaran Kesadara n :............... ................ ......GCS:..... ...........

TTV : TTV : TD:......................mmHg Nadi :..........x/menit o

Suhu :............ :............ C RR:...........x/menit Nyeri:................ Oksigen:.............L/ Oksigen :.............L/ menit

Infus :............. .tts/menit

Transfusi :..........tts/menit :..........tts/menit | Katheter:Y/T Katheter:Y/T | NGT: Y/T

TTV : TTV : TD:......................mmHg Nadi :..........x/menit o

Suhu :............ C RR:...........x/menit Nyeri:................ Oksigen:.............L/m Oksigen:. ............L/m enit

Infus :..............t ts/menit

Transfusi :..........tts/menit :..........tts/menit | Katheter:Y/T Katheter:Y/T | NGT: Y/T

TTV : TTV : TD:......................mmHg Nadi :..........x/menit Suhu :............ :............ oC RR:...........x/menit Nyeri:................ Oksigen:.............L/ Oksigen :.............L/ menit

Infus :............. .tts/menit

Transfusi :..........tts/menit :..........tts/menit | Katheter:Y/T Katheter:Y/T | NGT: Y/T

Makan/Minum :............ ................ ................. ............

Makan/Minum :.............. ............... ................ ............

Makan/Minum :............. ............... ................. ............

Toileting Toilet ing :............ ................. ................. ................. ...

Toileting Toileti ng :............... ................ ............... ................. ...

Toileting Toilet ing :............. ................ ................. ................. ...

 Aktivitas/Gerak :................. :........................... ................... ................... ................... .........

Aktivitas/Gerak :.................. :........................... ................... ................... .................. .........

Aktivitas/Gerak :................. :........................... ................... ................... ................... .........

Skore Jatuh :.............. ............... ................. ............ Recomendation :................................................... ............................................................................... ............................................................................... Pemberi Operan Penerima Operan

Skore Jatuh :............... ................ ................. .......... Recomendation :................................................... ............................................................................... ............................................................................... Pemberi Operan Penerima Operan

Skore Jatuh :............... .............. ................ ............. Recomendation :................................................... ............................................................................... ............................................................................... Pemberi Operan Penerima Operan

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