Formulir Transfer Pasien

RUMAH SAKIT

SARI ASIH FORMULIR TRANSFER PASIEN Nama Pasien

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

Jenis Kelamin

: L/P

Tanggal Lahir

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

Tanggal Masuk

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

DPJP

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

Ruang / Kamar

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

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

Tanggal / Jam Pindah

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

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

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

Diagnosis Masuk

Diagnnosis Sekarang

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

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

I. RINGKASAN RIWAYAT PASIEN Anamnesis Keluhan utama Riwayat penyakit

Pemeriksaan Fisik

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

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

Alasan transfer

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

II. PEMERIKSAAN PENUNJANG YANG SUDAH DILAKUKAN ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. III. TINDAKAN MEDIS YANG SUDAH DILAKUKAN ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. IV. PEMBERIAN TERAPI Infus : .............................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. Obat Injeksi : 1. ................................................................................................................... 2. ................................................................................................................... 3. ................................................................................................................... Obat Oral : 1. ................................................................................................................... 2. ................................................................................................................... 3. ................................................................................................................... 4. ................................................................................................................... Derajat kebutuhan perawatan pasien Derajat 0 Derajat 1

4. ................................................................................................................... 5. ................................................................................................................... 6. ................................................................................................................... 5. 6. 7. 8.

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

KATEGORI PASIEN TRANSFER Level Kategori Derajat 0 Pasien membutuhkan ruang perawatan biasa.

Pendamping TPK / Petugas keamanan

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

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.

V. KONDISI PASIEN Sebelum Transfer

Setelah Transfer

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

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

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

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

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