LEMBAR TRANSFER PASIEN.docx

LEMBAR TRANSFER INTERNAL I.

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IDENTITAS PASIEN Nama Pasien Jenis Kelamin Tanggal Lahir Diagnosis Masuk

: ....................................... : L/P : ....................................... : .......................................

RINGKASAN MEDIS Anamnesis  Keluhan  Riwayat alergi  Riwayat penyakit risiko tinggi Pemeriksaan fisik  Tanda vital  Keadaan umum Pemeriksaan penunjang  Laboratorium  Radiologi PEMBERIAN TERAPI  Infus 

Obat injeksi

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Obat oral

DPJP Tanggal masuk Ruang/ Kamar Status Pasien

: ....................................... : ....................................... : ....................................... : BPJS/ Asuransi*/ Pribadi

.............................................................................................................. .............................................................................................................. .............................................................................................................. td ...../..... mmHg; nadi ...... bpm; napas ..... x/i; suhu ..... oC .............................................................................................................. .............................................................................................................. ..............................................................................................................

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TINDAKAN MEDIS DAN OBSERVASI ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... .....................................................................................................................................................................

V.

KONDISI PASIEN Sebelum Transfer Keadaan umum : ...................................................... Kesadaran : ..................................................... Pemeriksaan tanda vital td ...../..... mmHg; nadi ...... bpm; napas ..... x/i; suhu ..... oC Catatan penting : ..................................................... ...................................................... .......................... Petugas yang menyerahkan Petugas Medis

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Setelah Transfer Keadaan umum : ..................................................... Kesadaran : .................................................... Pemeriksaan tanda vital td ...../..... mmHg; nadi ...... bpm; napas ..... x/i; suhu ..... oC Catatan penting : .................................................... ................................................................................ Petugas yang menerima Petugas Medis

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