Form Isian Sisrute

 

FORM DATA PASIEN YANG DIRUJUK DALAM APLIKASI SISRUTE

NO. REKAM MEDIS NAMA PASIEN NO. KONTAK  ALAMAT LENGKAP LENGKAP

TEMPAT LAHIR: TANGGAL LAHIR JENIS KELAMIN NO KARTU JKN NIK (KTP) TUJUAN RUJUK TRANSPORTASI PILIH AMBULANCE JENIS RUJUKAN  ALASAN RUJUKAN RUJUKAN

: ........................................................................................... ........................................ ................................................... ............................... : ........................................................................................... ........................................ ................................................... ............................... : ................................. (KELUARGA PENDAMPING ......................................) ................................. (PERAWAT PERUJUK ...............................................) ....................................... ........) : ................................................................... .................................. ............................................................................... ....................................................... ......... .......................................................................................................................... .......................................................................................................................... : (0000-00-00 / TAHUN-BULAN-HARI) TAHUN-BULAN-HARI) : LAKI/PEREMPUAN LAKI/PEREMPUAN : ...................................................................... ........................................ ......................................................................... .................................................... ......... : ........................................ .......................................................................... .............................................................................. ................................................ .... : RS .................................................................... .......................................... .......................................................................... ................................................ : AMBULANCE/PESAWA AMBULANCE/PESAWAT/KENDARAAN T/KENDARAAN AIR : NO PLAT ................................. DRIVER ......................................................... .......................... ............................... : RAWAT JALAN/RAWAT DARURAT : - PENANGANAN/PERAWA PENANGANAN/PERAWATAN TAN LANJUT PASIEN PASIEN (MEDIK) -  SARANA PRASARANA (RUANG PERAWATAN BIASA) -  SARANA PRASARANA (RUANG (RUANG INTENSIVE : ICU, NICU, PICU, HCU) -  SARANA PRASARANA (RUANG ISOLASI)

-  DOKTER SPESIALIS/SUB SPESIALIS TIDAK TERSEDIA -  TINDAKAN KHUSUS

DIAGNOSA KU PASIEN TTV NYERI

HASIL LAB

KETERANGAN : .......................................................................................................................... .......................................................................................................................... : ............................................................................................ ........................................ .................................................................. .............................. ................ .......................................................................................................................... : SADAR/TIDAK SADAR : TD ................. MMHG NADI .......... X/MENIT RR .......... X/MENIT SUHU ............ °C : BERAT/RINGAN/TIDAK BERAT/RINGAN/TIDAK NYERI KETERANGAN KETERANG AN LAIN (KELUHAN/PEMERIKSAA (KELUHAN/PEMERIKSAAN N FISIK) : .......................................................................................................................... ..........................................................................................................................

: ............................................................................................ ........................................ ........................................................................... .............................. ....... .......................................................................................................................... HASIL RADIOLOGI (RO, USG, EKG) : .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... TERAPI/TINDAKAN TERAPI/TINDAK AN YANG DIBERIKAN (INFUS, ( INFUS, INJEKSI, ORAL, TERPASANG ALAT INVASIF) : .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... ..........................................................................................................................