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REKAM MEDIS BENCANA ALAM RUMAH SAKIT MEDIKA MALANG Alamat : Jalan Tlogomas Nomor 22A Malang Telp:085979397 Kode Pos : 65112 e-mail:
[email protected]
Sheet Music
REKAM MEDIS BENCANA
NO RM : JENIS KELAMIN : NAMA :
Laki –laki
Umur/Tanggal Lahir
Perempuan
Alamat Pasien (Menurut KTP)
Rujukan: Ya Tidak
Keterangan RS Pusk lain
Jenis Bencana 1. Banjir 2. Tanah Longsor 3. Gunung Meletus 4. Gempa Bumi 5. Tsunami 6. ..........................
Jenis Cidera 1. Tumpul 2. Tajam 3. Peluru 4. Bakar 5. Keracunan 6. Tenggelam 7. Afiksia 8. .......................... Tanggal Ditemukan
Alergi :
Vital Sign:T
mmHg
N:
Dr
Bidan
x/mnt
R:
Perawat
IRJ-RSD
IRNA
Jam Ditemukan
x/menit
S:
°C
Nyeri
KONDISI
P1
P2
P3
GAWAT DAN DARURAT
GAWAT DAN
TIDAK GAWAT
TIDAK DARURAT
DAN TIDAK DARURAT
PEMERIKSAAN AWAL: Airway & C-Spine Bersih Slem sumbatan Partial Sumbatan Total Lain-lain
Pupil :isokor/anisokor :isokor/aniso kor Breathing Normal Whezzing Ronchi Retraction Nasal Flaring
Circulation Pallor Mottling Cyanosis Capilary Refill
Reflek cahaya: ............/........... ............/ ........... Disability Eksposure: GCS: Perdarahan Sign up to vote on this Eye Fraktur title Movement Parase useful Useful Not Reflek Plegi Motorik Paraperesis
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STATUS LOKALIS/ PEMERIKSAAN FISIK Tulislah lokasinya jika pada gambar tidak jelas
PEMERIKSAAN PSIKIATRI
Dilakukan
Tidak dilakukan
Bentuk Pikir : Realistik Non Realistik
Roman Muka: Banyak Mimik Sedikit mimik Apropiate In Apropiate
Isi Pikir: Waham Halusinasi Symtom Lain.........................
Progresi Pikir: Banyak Bicara Sedikit bicara Symtom Lain.................................. DIKERJAKAN JAM a Preview You're Reading
RENCANA TINDAKAN
Afek /Mood: Disforite Efori Symtom Lain......................................
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Dokter Triage
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(Dr................................ Tanda Tangan &Nama Len Sign up to vote on this title
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RENCANA PENGELOLAHAN DAN CATATAN PERKEMBANGAN
NAMA
:
UMUR
:
JENIS KELAMI :
PASIEN TERINTEGRASI
NO. RM
:
uliskan rencana pemeriksaan, tindakan, perawatan, rehabilitasi dan edukasi yang akan dijalankan berdasark Masalah yang ada (sesuai prioritas dan kegawatan) dan catatan perkembangan pasien
Tanggal/ Jam
PROFESI/ BAGIAN
HASIL PEMERIKSAAN,ANALISIS,RENCANA PENATALAKSANAAN PASIEN Harap Bubuhkan Stempel Nama dan Paraf tiap Akhir catatan)
Intruksi Tenaga Kesehatan
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Analisis SOAP S (SUBJEKTIF) O (OBJEKTIF) A() P(PLANNING)
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