Formulir-Transfer-Pasien.pdf

RUMAH SAKIT

SARI ASIH FORMULIR TRANSFER PASIEN Nama Pasien

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Jenis Kelamin

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 Tanggal  Ta nggal Lahir

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 Tanggal  Tang gal Masuk 

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DPJP

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Ruang / Kamar

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Dokter Konsulen 1 : .................. ..................................... ..................................... ..................................... .................................. ...............

 Tanggal  Tang gal / Jam Pindah

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Dokter Konsulen 2 : .................. ..................................... ..................................... ..................................... .................................. ...............

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

Diagnosis Masuk 

Diagnnosis Sekarang

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I. RINGKAS RINGKASAN AN RIWAY RIWAYAT PASIEN PASIEN

Anamnesis Keluhan utama

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Riwayat penyakit

Pemerik Pem eriksaan saan Fisi Fisikk

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Pemeriksaan Peme riksaan tanda-tanda vital : Keadaan umum

Alasan transfer

Tensi Ten si :

mmHg

Suhu :

0

C

Nadi :

x/mnt

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II. PEMERIKSAAN PENUNJANG YANG YANG SUDAH DILAKUKAN

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

............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. IV. PEMBERIAN PEMBER IAN TERAPI

Infus : .............................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. Obat Injeksi : 1. ...................................................................................................................

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3. ................................................................................................................... Obat Oral :

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4. ................................................................................................................... Derajat kebutuhan perawatan pasien Derajat 0 Derajat 1

8. ................................................................................................................... Derajat 2 Derajat 3

KATEGORI PASIEN TRANSFER Level

Kategori

Pendamping

Peralatan

Derajat 0

Pasien membutuhkan ruang perawatan biasa.

 TPK / Petugas keamanan

Derajat 1

Pasien beresiko mengalami perburukan, pasien baru pindah dari HCU/ICU, pasien yang akan dirawat diruang perawatan tim perawatan khusus.

Petugas PK I  / Petugas keamanan

Derajat 2

Pasien memerlukan pengawasan ketat atau intervensi khusus, mis : pada pasien yang mengalami kegagalan satu sistem organ.

Dokter/Perawat PK II

Peralatan derajat 1, + bedside monitor, syringe pump.

Derajat 3

Pasien mengalami kegagalan multi organ dan memerlukan bantuan hidup jangka panjang ditambah dengan kebutuhan akan alat bantu nafas.

Dokter/Perawat PK III

Peralatan derajat 2, + alat bantu nafas.

Semua rekam medik, hasil pemeriksaan penunjang, format transfer internal Peralatan derajat 0+ tabung oksigen dan canul, stand infus dan pulse oksimetri.

V. KONDISI PASIEN Sebelum Transfer

Setelah Transfer

Keadaan umum : ...................................................................................... Kesadaran : ...................................................................................... Pemeriksaan tanda-tanda vital :  Tensi : mmHg 0 Suhu : C Nadi : x/mnt

Keadaan umum : ...................................................................................... Kesadaran : ...................................................................................... Pemeriksaan tanda-tanda vital :  Tensi : mmHg 0 Suhu : C Nadi : x/mnt

Catatan penting : ............................................. .........................................   ......................................................................................   ......................................................................................   ......................................................................................

Catatan penting : .................................................. ....................................   ......................................................................................   ......................................................................................   ......................................................................................

Petugas yang menyerahkan

Petugas yang menerima

Petugas Medis

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Petugas Medis

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